The introduction of extracorporeal membrane oxygenation to aeromedical evacuation.

Objective: To review the principles of extracorporeal membrane oxygenation (ECMO) and to describe the recent advancements in ECMO technology that permit use of this rescue therapy for severe lung injury in combat casualties.

Methods/results: Lung protective ventilation has defined the state-of-the-art treatment for acute lung injury for more than a decade. Despite the benefits provided by a low tidal volume strategy, lung injury patients may experience deterioration in gas exchange to the point that other rescue interventions are needed or the patient succumbs to progressive respiratory failure.

Closing the "care in the air" capability gap for severe lung injury: the Landstuhl Acute Lung Rescue Team and extracorporeal lung support.

Background: The success of US Air Force Critical Care Air Transport Teams (CCATT) in transporting critically ill and injured patients enabled changes in military medical force deployment and casualty care practice. Even so, a subset of casualties remains who exceed even CCATT capabilities for movement. These patients led to the creation of the Landstuhl Acute Lung Rescue Team (ALeRT) to close the "care in the air" capability gap.

Reversal of hemorrhagic shock-associated hepatic ischemia-reperfusion injury with N-acetylcysteine.

Background: The underpinning pathophysiology, prevalence, and clinical relevance particular to hemorrhagic shock-induced liver damage have been explored only recently. Importantly, several investigators have revealed that an aberrant periportal endothelial response, characterized by the early release of oxidizing mediators, perpetuates and eventually amplifies the extent of hepatic reperfusion injury.

Case: We present a case that illustrates the clinical impact of hepatic ischemia-reperfusion injury and a potential means of ameliorating the attendant self-propagating hepatic destruction.

High-frequency percussive ventilation and low tidal volume ventilation in burns: a randomized controlled trial.

Objectives: In select burn intensive care units, high-frequency percussive ventilation is preferentially used to provide mechanical ventilation in support of patients with acute lung injury, acute respiratory distress syndrome, and inhalation injury. However, we found an absence of prospective studies comparing high-frequency percussive ventilation with contemporary low-tidal volume ventilation strategies. The purpose of this study was to prospectively compare the two ventilator modalities in a burn intensive care unit setting.

High-frequency percussive ventilation revisited.

High-frequency percussive ventilation (HFPV) has demonstrated a potential role as a rescue option for refractory acute respiratory distress syndrome and as a method for improving inhalation injury outcomes. Nevertheless, there is a lack of literature examining the practical application of HFPV theory toward either improving gas exchange or preventing possible ventilator-induced lung injury. This article will discuss the clinically pertinent aspects of HFPV, inclusive of high- and low-frequency ventilation.

Inhaled prostacyclin in combination with high-frequency percussive ventilation.

We present a case of severe acute respiratory distress syndrome pursuant to inhalation of a compressed gas computer keyboard cleaner. Despite the use of multimodal therapy to include empiric antibiotics, intravenous paralytics, intravenous concentrated albumin, high-dose corticosteroids as well as sustained high mean airway pressure mechanical ventilation by airway pressure release and high-frequency percussive ventilation (HFPV) modes, the patient demonstrated an unchanging arterial oxygen tension/fraction of inspired oxygen ratio of only 57 mm Hg. A trial of nebulized prostacyclin was initiated during HFPV leading to a significant improvement in arterial oxygen tension/fraction of inspired oxygen to 147 mm Hg.

Glucose variability is associated with high mortality after severe burn.

Background: Hyperglycemia is associated with increased mortality in the severely injured; intensive insulin protocols reduce mortality, improve wound healing, and decrease susceptibility to infection. High glucose variability creates challenges to glycemic control and may be a marker of poor outcome. We wondered whether glycemic variability alone might identify patients at higher risk of death.

Critical care at Landstuhl Regional Medical Center.

Background: Landstuhl Regional Medical Center is the largest U.S. medical facility outside the United States, and it is the first permanently positioned hospital outside the combat zone providing care to the wartime sick and wounded.

Global evacuation of burn patients does not increase the incidence of venous thromboembolic complications.

Background: Case-control studies have suggested that air travel may be a risk factor for the development of Venous Thromboembolism (VTE). Burned patients from the current war in Iraq and Afghanistan, are transported across three continents to our Burn Center with total ground and air transport time being approximately 24 hours spread over 3 days to 4 days. We hypothesized global evacuation results in increased VTE rates.

Long range transport of war-related burn casualties.

Background: US military burn casualties are evacuated to the US Army Institute of Surgical Research Burn Center in San Antonio, TX. Patients are transported by US Army Institute of Surgical Research Burn Flight Teams, Air Force Critical Care Air Transport Teams, or routine aeromedical evacuation. This study characterizes the military burn casualties transported by each team and reports associated outcomes.

Patterns of exogenous insulin requirement reflect insulin sensitivity changes in trauma.

Introduction: We investigated patterns of blood glucose and exogenous insulin requirement in the intensive care unit, and questioned whether they reflect fluctuations in insulin activity.

Methods: Records for burn intensive care unit patients with 7 days of glucose control with insulin were reviewed. Hourly blood glucose and insulin dose were matched for time collected and analyzed with linear and cosine regression.

Metabolic response to injury and role of anabolic hormones.

Purpose Of Review: To provide a short review of the literature describing the hypermetabolic response to injury and potential treatments. Associated findings include changes in inflammatory mediators and secreted hormones.

Recent Findings: Treatments should be aimed at decreasing the response and potentially the use of anabolic agents.

Comparison between civilian burns and combat burns from Operation Iraqi Freedom and Operation Enduring Freedom.

Objective: To assess outcome differences between locally burned civilians and military personnel burned in a distant combat zone treated in the same facility.

Summary Background Data: The United States Army Institute of Surgical Research (USAISR) Burn Center serves as a referral center for civilians and is the sole center for significant burns in military personnel. We made the hypothesis that outcomes for military personnel burned in the current conflict in Iraq and Afghanistan would be poorer because of delays to definitive treatment, other associated injury, and distance of evacuation.

Blunt thoracic trauma: flail chest, pulmonary contusion, and blast injury.

Blunt thoracic trauma can result in significant morbidity in injured patients. Both chest wall and the intrathoracic visceral injuries can lead to life-threatening complications if not anticipated and treated. Pain control, aggressive pulmonary toilet, and mechanical ventilation when necessary are the mainstays of supportive treatment.

Absorbable plates for rib fracture repair: preliminary experience.

Background: Absorbable prostheses are currently used in a variety of bone reconstructions and fixations.

Methods: This is a case series of rib fracture fixation using absorbable plates and screws consisting of 70:30 poly(L-lactide-co-D,L-lactide) from April 2001 through November 2002.

Results: Ten patients underwent rib fracture fixation with absorbable plates and screws.

Cricothyroidotomy for elective airway management in critically ill trauma patients with technically challenging neck anatomy.

Introduction: To assess the value of elective cricothyroidotomy for airway management in critically ill trauma patients with technically challenging neck anatomy.

Materials And Methods: A retrospective chart review of patients admitted to the Trauma Service at a Level I Trauma Center who underwent cricothyroidotomy for elective airway management over a 40-month period from January 1997 to April 2000. Comparison was made with a cohort of Trauma Service patients who received a tracheostomy.

A protocolized approach to pulmonary failure and the role of intermittent prone positioning.

Introduction: We present a series of adult patients treated under a protocol for severe lung failure (acute respiratory distress syndrome [ARDS]) that uses positive end-expiratory pressure (PEEP) optimization and intermittent prone positioning (IPP) to reduce shunt, improve oxygen (O(2)) delivery, and reduce FiO(2).

Methods: Trauma, emergency vascular, and general surgical patients with PaO(2)/FiO)(2) (PF) ratio < 200 were entered into a protocol designed to maintain mixed venous saturation (SVO(2)) > 70% with FiO(2) < 0.50.