Search

Acute pulmonary embolism (PE) affects over 600,000 Americans per year and is a common diagnostic consideration among emergency department patients. Although there are well-documented differences in the diagnosis, treatment, and outcomes of cardiovascular conditions, such as ischemic heart disease and stroke, the influence of sex and gender on PE remains poorly understood. The overall age-adjusted incidence of PE is similar in women and men, but women have higher relative rates of PE during early and mid-adulthood (ages 20-40 years); whereas, men have higher rates of PE after age 60 years. Women are tested for PE at far higher rates than men, yet women who undergo computed tomography pulmonary angiography are ultimately diagnosed with PE 35%-55% less often than men. Among those diagnosed with PE, women are more likely to have severe clinical features, such as hypotension and signs of right ventricular dysfunction. When controlled for PE severity, women are less likely to receive reperfusion therapies, such as thrombolysis. Finally, women have more bleeding complications for all types of anticoagulation. Further investigation of possible sex-specific diagnostic and treatment algorithms is necessary in order to more accurately detect and treat acute PE in non-pregnant adults.

Exposures to hydrazines occur during aeronautic and space operations and pose a potential risk to personnel. Historically, extensive preparatory countermeasures have been taken due to concern for severe toxicity. This study seeks to better understand manifestations of acute occupational exposures to hydrazine to guide recommendations for management. A retrospective database review of records from four United States regional poison centers was conducted of all human exposures to hydrazine, monomethylhydrazine, or 1,1-dimethylhydrazine over two decades. Following case abstraction, descriptive statistics were performed to characterize demographics, manifestations, treatments, and outcomes. One hundred and thirty-five cases were identified, and most were adult males exposed to inhaled hydrazine propellant vapors. Fifty-seven percent of patients were asymptomatic following exposure; otherwise, common symptoms were dyspnea, throat irritation, cough, ocular irritation, and headache. All patients were evacuated or received decontamination, with a few reports of symptomatic treatments, including oxygen supplementation and salbutamol (albuterol). Patients usually recovered quickly and were released after a brief healthcare facility evaluation or observed locally. No patients developed delayed symptoms. Symptoms of severe toxicity were not observed, and there were no deaths. Acute exposures to hydrazines during operations within the aerospace industry appear to be limited primarily to mucosal and mild pulmonary irritation without significant neurologic, hepatic, or hematologic toxicity. These findings are contrary to previously established expectations and may be related to low-level exposures or possibly due to current emergency countermeasures. Care in occupational hydrazine exposure will focus on evacuation, decontamination, and symptomatic management of chemical irritant properties of hydrazines. It is reasonable to manage mild cases outside of a healthcare facility. Continued endeavors in human space exploration and habitation will increase the risk of these exposures, making it imperative that clinicians be comfortable with the care and management of these patients. [ABSTRACT FROM AUTHOR]

Introduction: Critical Care Air Transport Team (CCATT) is a three-person United States Air Force (USAF) medical asset, typically providing intercontinental medical evacuation on large military aircraft. The CCATT equipment Allowance Standard (AS) weighs approximately 272 kg (600 lbs). In austere locations, CCATT teams may augment contract medical evacuation (CME) personnel or Pararescue (PJ) in small aircraft with limited space for medical equipment. It was unknown what deployed PJ and CME carry within their packouts. We sought to design a packout or "Go Bag," weighing less than 22.7 kg (50 lbs) and sourced from the CCATT AS, that a CCATT member could use to complement CME or PJ equipment to provide a higher level of care while limiting redundancy. Materials and Methods: Equipment lists were obtained from a CME and PJs from two separate USAF squadrons. The equipment lists were combined to provide a reference for development of a CCATT Go Bag. Three members of a deployed CCATT team independently generated a list of necessary equipment from the CCATT AS. The list was peer reviewed by a separate, deployed CCATT team. Results: A Go Bag was developed with the supplies and equipment necessary for video laryngoscopy, ventilation, invasive pressure monitoring, basic laboratory capability, chest tube placement, ultrasound, and advanced pharmacologic interventions. The Go Bag weighed 18.3 kg (40.4 lbs). A separate respiratory bag weighing 1.1 kg (2.4 lbs) was attached directly to a ventilator. Intravenous pumps and cardiac monitoring equipment were notable ICU equipment excluded from the Go Bag. Conclusion: Major components of the CCATT AS can be reduced into a Go Bag and accompanying Ventilator Accessory Bag. This may benefit CCATT teams required to augment PJs or CME in small aircraft during prolonged field care scenarios. [ABSTRACT FROM AUTHOR]

INTRODUCTION: I nhalation of hydrazine or hydrazine-derivative (for example, monomethylhydrazine) vapors during spaceflight operations remains a risk to crew and ground support personnel. Here we sought to provide an evidence-based approach to inform acute clinical treatment guidelines for inhalational exposures during a noncatastrophic contingency spaceflight recovery scenario. METHODS: A review of published literature was conducted concerning hydrazine/hydrazine-derivative exposure and clinical sequelae. Priority was given to studies that described inhalation though studies of alternative routes of exposure were additionally reviewed. Where possible, human clinical presentations were prioritized over animal studies. RESULTS: Rare human case reports of inhalational exposure and multiple animal studies provide evidence of varied clinical sequelae, including mucosal irritation, respiratory concerns, neurotoxicity, hepatotoxicity, hemotoxicity (including Heinz body development and methemoglobinemia), and longitudinal risks. In an acute timeframe (minutes to hours), clinical sequelae are likely to be limited to mucosal and respiratory risk; neurological, hepatotoxic, and hemotoxic sequelae are unlikely without recurrent, longitudinal, or noninhalational exposure. CONCLUSIONS: Acute clinical management should focus on likely clinical concerns as supported by existing data; recovery medical personnel should be prepared to manage mucosal irritation and respiratory concerns, including the potential need for advanced airway management. There is little evidence supporting the need for acute interventions for neurotoxicity and there is no evidence that acute hemotoxic sequelae would drive the need for on-scene management of methemoglobinemia, Heinz body development, or hemolytic anemia. Training that overemphasizes neurotoxic or hemotoxic sequelae or specific treatments for such conditions potentially raises the risk for inappropriate treatment or operational fixation. [ABSTRACT FROM AUTHOR]

Background: Evidence from military populations showed that resuscitation using whole blood (WB), as opposed to component therapies, may provide additional survival benefits to traumatically injured patients. However, there is a paucity of data available for the use of WB in uninjured patients requiring transfusion. We sought to describe the use of WB in non-trauma patients at Brooke Army Medical Center (BAMC).Materials and Methods: Between January and December 2019, the BAMC ClinComp electronic medical record system was reviewed for all patients admitted to the hospital who received at least one unit of WB during this time period. Patients were sorted based on their primary admission diagnosis. Patients with a primary trauma-based admission were excluded.Results: One hundred patients were identified who received at least one unit of WB with a primary non-trauma admission diagnosis. Patients, on average, received 1,064 mL (750-2,458 mL) of WB but received higher volumes of component therapy. Obstetric/gynecologic (OBGYN) indications represented the largest percentage of non-trauma patients who received WB (23%), followed by hematologic/oncologic indications (16%).Conclusion: In this retrospective study, WB was most commonly used for OBGYN-associated bleeding. As WB becomes more widespread across the USA for use in traumatically injured patients, it is likely that WB will be more commonly used for non-trauma patients. More outcome data are required to safely expand the indications for WB use beyond trauma. [ABSTRACT FROM AUTHOR]

Introduction Chest radiography is a diagnostic tool commonly used by medical providers to assess high-altitude pulmonary edema (HAPE). Although HAPE often causes a pattern of pulmonary edema with right lower lung predominance, previous research has shown that there is no single radiographic finding associated with the condition. The majority of research involves a retrospective analysis of chest radiographs taken at the time of HAPE diagnosis. Little is known about the radiographic progression of HAPE during treatment or medical evacuation. Materials and Methods Three sequential chest radiographs were obtained from two patients diagnosed with HAPE at the Amundsen-Scott South Pole Station, Antarctica, who required treatment and medical evacuation. Deidentified and temporally randomized images were reviewed in a blinded fashion by two radiologists. A score of 0 (normal lung) to 4 (alveolar disease) was assigned for each of the four lung quadrants for an aggregate possible score ranging from 0 to 16 for each radiograph. Results Patient 1's initial radiograph showed severe HAPE with an initial score of 13. Despite a rapid clinical improvement after medical evacuation, he continued to show multifocal radiographic evidence of disease in all the lung quadrants on day 1 (score of 11) and day 2 (score of 5). Patient 2's radiographs showed less severe disease at presentation (score of 6). Despite the need for continued treatment, his radiographs showed a rapid improvement, with radiographic score decreasing to 3 on day 1 and 1 on day 3. Conclusion The chest radiographs showed serial improvement after medical evacuation in both patients. There was not a strong correlation between clinical symptoms and radiographic severity in subsequent images. [ABSTRACT FROM AUTHOR]

Treatment with β2‐agonists may cause elevated lactic acid, the end product of anaerobic metabolism of glucose. It has been proposed that lactic acidosis associated with β2‐agonists is caused by changes to direct biochemical impacts on glycolysis, gluconeogenesis, pyruvate metabolism, and free fatty acid production. However, much remains unknown, and there is a paucity of evidence regarding the underlying chemical changes associated with this lactic acidosis. The goal of our study was to investigate the impact of 1 hour of continuous albuterol on the untargeted serum metabolome of healthy subjects. Twenty‐four healthy participants received 7.5 mg of continuous albuterol for 1 hour. Baseline, 1‐hour, and 2‐hour lactic acid levels were drawn. Samples obtained at baseline and 1 hour were sent for untargeted metabolomic profiling. Participants had a baseline lactic acid of 1.45 ± 0.46 mmol/L. On average, lactate levels increased 0.33 ± 0.67 mmol/L after 1 hour (P =.02) and remained elevated at 2 hours (0.32 ± 0.72 mmol/L, P =.02), although there was overlap in lactate levels across times. For metabolomic analysis, fatty acids, organic acids, and sugars were elevated, and amino acids were reduced. Lactic acid and pyruvic acid metabolites, however, did not significantly change (after false discovery rate adjustment). In healthy participants, continuous albuterol alters the serum metabolome, but this change may not be clinically significant. The data support recent hypotheses that β2‐receptor activation stimulates lactic acid production, altering aerobic glycolysis, gluconeogenesis, and free fatty acid production. [ABSTRACT FROM AUTHOR]