Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for Use in Temporizing Intra-Abdominal and Pelvic Hemorrhage: Physiologic Sequelae and Considerations.

REBOA has been used for several years by acute care surgeons for temporization of intra-abdominal, pelvic, and junctional hemorrhage. The physiology and consequences of aortic occlusion in these patients are largely unstudied.

Trends in warfarin use and its associations with thromboembolic and bleeding rates in a population with atrial fibrillation between 1996 and 2011.

AIM: Warfarin is a cornerstone for the prevention of thromboembolism in atrial fibrillation (AF), and several efforts have been taken to increase its usage and safety, including risk stratification schemes. Our aim was to investigate the temporal trends in initiation of warfarin and its effects on incidence of bleeding and thromboembolism in patients with new-onset atrial fibrillation 1996-2011. METHODS: All patients with a first-time diagnosis of non-valvular atrial fibrillation were identified from nationwide administrative registries. Trends were determined by linear regression. RESULTS: In total 153,682 patients were included. Initiation of warfarin increased from 14% to 41% (p<0.0001). Events of thromboembolism decreased from 3.9% to 2.6% annually (p<0.0001). The greatest decline in thromboembolic events was observed for patients with a CHA2DS2VASc score >1, where the annual decline was -0.12% (95%CI: -0.161; -0.084)) for those treated with warfarin and -0.073% (95%CI: -0.116;-0.030)) for those not treated with warfarin. Bleeding increased from 3.3% to 3.9% (p = 0.043). For those with a CHA2DS2VASc score >1 annual bleeding rates increased by 0.095% (95%CI: -0.025; -0.165) in warfarin treated and by 0.056% (95%CI: -0.013; -0.100) in patients not treated with warfarin. CONCLUSION: Warfarin use increased by nearly a 3-fold between 1996 and 2011. During the same period, thromboembolic events declined by a third and bleeding increased by a fifth, suggesting a beneficial effect associated with higher warfarin use. Notably, a small decline in thromboembolic events and increase in bleeding events was observed for the untreated population, suggesting a changing risk profile of AF patients.

How hemorrhage control became common sense.

BACKGROUND: Just over 200 years ago, surgeons were puzzled that the use of the tourniquet to control hemorrhage as common sense during surgery was a relatively recent development. Within the last 20 years, much progress has been made to controlling hemorrhage in the prehospital context. Then, as now, it was surprising that progress on something that appeared obvious had occurred only recently, begging the question how controlling blood loss was common sense in a surgical context, but not for emergency treatment. METHODS: This article is a historical survey of the evolution of the medical understanding of hemorrhage along with technological response. RESULTS: The danger of blood loss had historically been consistently underestimated as physicians looked at other explanations for symptoms of how the human body responded to trauma. As the danger from hemorrhage became apparent, even obvious, responsibility for hemorrhage control was delegated down from the surgeon to the paramedic and eventually to individual service members and civilian bystanders with training to "stop the bleed." CONCLUSION: Hippocratic medicine assumed that blood diffused centrifugally into periphery through arteries. William Harvey's observation in 1615 that blood ran through a closed circulatory system gradually transformed conventional wisdom about blood loss, leading to the development of the tourniquet about a century later by Jean-Louis Petit, which made amputation of limbs survivable. However, physicians were cautious about their application during the First World War over concerns over effects on patient recovery. Hemorrhage had generally been seen as symptom to be managed until the patient would be seen by a surgeon who would stop the bleeding. More thorough collection and analysis of data related to case histories of soldiers wounded during the Vietnam Conflict transformed how surgeons understood the importance to hemorrhage leading to development of the doctrine of Tactical Combat Casualty Care in the late 1990s. LEVEL OF EVIDENCE: Background Information: Economic/decision study.

The aspirin story - from willow to wonder drug.

The story of the discovery of aspirin stretches back more than 3500 years to when bark from the willow tree was used as a pain reliever and antipyretic. It involves an Oxfordshire clergyman, scientists at a German dye manufacturer, a Nobel Prize-winning discovery and a series of pivotal clinical trials. Aspirin is now the most commonly used drug in the world. Its role in preventing cardiovascular and cerebrovascular disease has been revolutionary and one of the biggest pharmaceutical success stories of the last century.

Emergencies and acute diseases in the collected works of Hippocrates: observation, examination, prognosis, therapy.

The collected works οf Hippocrates include a wealth of references to emergencies and acute conditions; if the physician could treat these, he would be considered superior to his colleagues. Works most relevant to current Emergency Medicine are presented. They indicate Hippocrates' remarkable insight and attention to the value of close observation, meticulous clinical examination, and prognosis. Hippocrates and his followers disdained mystery and were not satisfied until they had discovered a rational cause to diseases. They assigned great significance to distressing signs and symptoms - the famous Hippocratic face, the breathing pattern, pain, seizures, opisthotonus - pointing to a fatal outcome, which they reported to their patient. The principles of treatment of emergencies, such as angina, haemorrhage, empyema, ileus, shoulder dislocations and head injuries, are astonishingly similar to the ones used nowadays.

Cullen Sign and Grey Turner Sign Revisited.

Cullen sign and Grey Turner sign, named after Thomas Stephen Cullen, MB, and George Grey Turner, MBBS, respectively, are signs of abdominal wall hemorrhage and are generally associated with acute pancreatitis. However, the research from which these signs arose was documented long before Cullen and Grey Turner made their contributions. The present article examines the history, pathologic mechanisms, and clinical application of these signs in relation to acute pancreatitis and ectopic pregnancy.

Over 50 Years of Fibrinogen Concentrate.

March 2013 represented the 50th anniversary of the first license granted for a fibrinogen concentrate. In this review, we look at the history of bleeding management that led to the development of fibrinogen concentrate, discuss its current use, and consider future developments for this product.

Long-Acting Anticoagulant Rodenticide (Superwarfarin) Poisoning: A Review of Its Historical Development, Epidemiology, and Clinical Management.

Long-acting anticoagulant rodenticides (LAARs) inhibit vitamin K epoxide reductase (VKOR). Related bleeding may present a diagnostic challenge and require administration of blood component therapy, hemostatic agents, and vitamin K. This article intends to provide the reader a comprehensive understanding of LAAR poisoning. An exhaustive literature search of PubMed, Science Direct, US National Library of Medicine Toxicology Data Network, and Google Scholar yielded 174 reported cases of LAAR poisoning from which clinical data were extracted and reviewed. In addition, 25 years of epidemiologic data from the American Association of Poison Control Centers was reviewed. In the United States, on average, there were 10413 exposures reported with 2750 patients treated annually. For 25 years, there were 315951 exposures reported with nearly 90% among children and more than 100000 patients treated in a health care facility. Fortunately, only 2% of all exposures result in morbidity or mortality. Inhalational, transcutaneous, and oral routes of exposure have been documented. Most exposures are unintentional. The most frequently reported bleeding sites are mucocutaneous, with hematuria being the most common feature. Deaths were most commonly associated with intracranial hemorrhage. Long-acting anticoagulant rodenticide-induced paradoxical thrombosis and thrombotic complications accompanying hemostatic therapy have also been observed. Most patients present with coagulation assay values beyond measurable limits. Long-acting anticoagulant rodenticides have an extremely high affinity for VKOR compared with warfarin, characterized by rebound coagulopathy and bleeding after initial treatment and the need for high-dose, long-term therapy with vitamin K1. Treatment of acute hemorrhagic symptoms often required intravenous vitamin K1 in excess of 50 to 100 mg; chronic maintenance with 100 mg PO vitamin K1 daily was the most frequently used dose required to suppress coagulopathy. Treatment courses averaged 168 days. Adjunctive hemostatic therapy with recombinant factor VIIa and prothrombin complex concentrate has been reported, and phenobarbital has been used to expedite LAAR metabolism.

[Acupuncture theory of promoting blood circulation and removing stasis and its clinical application].

The effects and methods of acupuncture on promoting blood circulation and removing stasis and its importance for modern clinical acupuncture are explored and explained. The acupuncture theory of promoting blood circulation and removing stasis in Internal Canon of Yellow Emperor and the ancient medical scholars' knowledge of acupuncture for promoting blood circulation and removing stasis are traced, and then the principles and characteristics of acupuncture for promoting blood circulation and removing stasis are explored and summarized. The methods and common tools of prompting blood circulation and removing stasis of modern clinical acupuncture are summed up as well. It is considered that the treatment principles and methods of acupuncture for prompting blood and removing stasis deserve to be paid attention to and applied by all departments of clinical acupuncture.

Lessons from 150 years of UK maternal hemorrhage deaths.

We have reviewed maternal hemorrhage death rates in the UK over the past 150 years in order to draw lessons from this material for current attempts to reduce global maternal mortality. Mortality rates from data in the UK Annual Reports from the Registrar General were entered into a database. Charts were created to display trends in hemorrhage mortality, allowing comparison with historical medical advances. Hemorrhage death rates fell steadily before the 1930s; between 1874 and 1926 they fell by 56%. In contrast, there was no consistent reduction in overall maternal mortality rates until the 1930s; from 1932 to 1952 they fell by 85%, primarily due to a reduction in sepsis deaths. In conclusion the majority of maternal hemorrhage mortality reductions in the UK occurred prior to the availability of effective oxytocics, antibiotics, and blood transfusion. Improving access to and standards of maternal care is key to addressing global maternal mortality today.

Innocent blood: a history of hemorrhagic disease of the newborn.

Hemorrhages occurring in the newborn without trauma have been observed by obstetricians since the 17th century, but have been considered different diseases depending on their location. Umbilical hemorrhage associated with obstructed bile canals was described by Cheyne in 1802. Grandidier in 1871 and Townsend in 1894 grouped together various forms of neonatal bleeds and associated them with disturbed coagulation. When the clotting system became better understood in the last decade of the 19th century, effective symptomatic treatment was developed: gelatin, serum injection, and the transfusion of fresh blood. In 1935, Dam detected the function of vitamin K in the coagulation system and 4 years later, Waddell introduced vitamin K administration into therapy and prevention of neonatal hemorrhagic disease. Kernicterus occurred when high doses of synthetic water-soluble vitamin K analogues were given to preterm infants, reminding physicians that progress in neonatal therapy rests on the cornerstones of controlled trials and follow-up.

Vascular access and closure in coronary angiography and percutaneous intervention.

The key feature defining transcatheter cardiovascular interventions is that access to the vessels and heart is achieved by arterial puncture with a needle, rather than surgical incision with a scalpel. However, arteriotomy and vessel closure are performed without direct visualization of the arterial wall, which risks vessel damage and bleeding. Vascular closure devices offer the potential for enhanced control of access-site haemostasis and reduced complications in comparison with manual compression. However, although randomized clinical trials have shown reductions in time to haemostasis and ambulation, the data do not demonstrate consistent reductions in access-site complications or improvements in clinical outcomes. Another approach to increase the safety of percutaneous procedures is to use radial, rather than femoral, arterial access, a strategy that has polarized opinions among cardiologists. Clinical trial data show a clear reduction in access-site bleeding and complications with radial access, at the expense of a marginal increase in markers of procedural efficiency. However, randomized trials have not demonstrated improved clinical outcomes with radial access. The lack of impact on prognostically relevant bleeding events could explain this null finding, although the setting of primary percutaneous coronary intervention could be an exception. Ongoing, iterative improvement in catheter technologies, as well as in adjuvant antiplatelet and antithrombotic therapies, are likely to underlie the difficulty in demonstrating clear outcome benefits with different vascular access and closure strategies.

Cryoprecipitate: an outmoded treatment?

Cryoprecipitate is an allogeneic blood product prepared from human plasma. It contains factors VIII, von Willebrand factor (vWF), fibrinogen, fibronectin and factor XIII. Its use was first described in the 1960s for treatment of patients with factor VIII deficiency. It has also been used to treat patients with congenital hypofibrinogenaemia. Now, the most common use of cryoprecipitate is fibrinogen replacement in patients with acquired hypofibrinogenaemia and bleeding. Despite almost 50 years of use, evidence of efficacy is limited. This review provides an overview of the history of cryoprecipitate use, the current debates on the use of this product and future developments.

Historical review of emergency tourniquet use to stop bleeding.

BACKGROUND: Although a common first aid topic, emergency tourniquets to stop bleeding are controversial because there is little experience on which to guide use. Absent an adequate historical analysis, we have researched development of emergency tourniquets from antiquity to the present. METHODS: We selected sources emphasizing historical development of tourniquets from books and databases such as PubMed. RESULTS: The history of the emergency tourniquet is long and disjointed, mainly written by hospital surgeons with little accounting, until recently, of the needs of forward medics near the point injury. Many investigators often are unaware of the breadth of the tourniquet's history and voice opinions based on anecdotal observations. CONCLUSIONS: Reporting the historical development of tourniquet use allowed us to recognize disparate problems investigators discuss but do not recognize, such as venous tourniquet use. We relate past observations with recent observations for use by subsequent investigators.