Thromboelastographic changes in patients experiencing an acute ischemic stroke and receiving alteplase.

BACKGROUND: Thromboelastography is a method of measuring whole-blood coagulation changes and has been used to guide therapy and monitor changes in a variety of disease states. However, few studies have investigated the thromboelastographic changes experienced in a patient who has received alteplase for an acute ischemic stroke. This pilot study sought to describe the effect of alteplase on the thromboelastogram tracings of patients experiencing an acute ischemic stroke. METHODS: This was an institutional review board-approved prospective cohort study. Patients who presented to the emergency department with symptoms of acute ischemic stroke and received intravenous alteplase were evaluated for inclusion. Blood samples were obtained before alteplase administration and at 30, 60, 90, 120, and 150 minutes after alteplase administration. In addition, baseline variables collected included patient age, sex, prothrombin time, partial thromboplastin time, and the use of pretreatment anticoagulants or antiplatelet agents. Patients were also followed throughout their hospital stay for development of intracranial hemorrhage. RESULTS: A total of 7 patients were included in the analysis. At baseline, thromboelastogram parameters of all patients were within the normal range. The maximum inhibition of fibrin buildup was seen at 30 minutes after the start of alteplase infusion, and the lowest clot strength was observed at 60 minutes after initiation of alteplase. Most patients return to near baseline parameters within 150 minutes of alteplase initiation; however, 2 patients did not return to their baseline values within the 150-minute time frame. CONCLUSIONS: Our study suggests that thromboelastogram (TEG) is a useful tool for determining changes in the coagulation system of patients whom have received recombinant tissue plasminogen activator (rt-PA). Further study is needed to determine if TEG can be used to predict those patients who may be at higher risk of adverse events because of rt-PA.

Scottish urban versus rural trauma outcome study.

BACKGROUND: Outcome following trauma and health care access are important components of health care planning. Resources are limited and quality information is required. We set the objective of comparing the outcomes for patients suffering significant trauma in urban and rural environments in Scotland. METHOD: The study was designed as a 2 year prospective observational study set in the west of Scotland, which has a population of 2.58 million persons. Primary outcome measures were defined as the total number of inpatient days, total number of intensive care unit days, and mortality. The participants were patients suffering moderate (ISS 9-15) and major (ISS>15) trauma within the region. The statistical analysis consisted of chi square test for categorical data and Mann Whitney U test for comparison of medians. RESULTS: There were 3,962 urban (85%) and 674 rural patients (15%). Urban patients were older (50 versus 46 years, p = 0.02), were largely male (62% versus 57%, p = 0.02), and suffered more penetrating traumas (9.9% versus 1.9%, p < 0.001). All prehospital times are significantly longer for rural patients (p < 0.001), include more air ambulance transfers (p < 0.001), and are characterized by greater paramedic presence (p < 0.001). Excluding neurosurgical and spinal injuries transfers, there was a higher proportion of transfers in the rural major trauma group (p = 0.002). There were more serious head injuries in the urban group (p = 0.04), and also a higher proportion of urban patients with head injuries transferred to the regional neurosurgical unit (p = 0.037). There were no differences in length of total inpatient stay (median 8 days, p = 0.7), total length of stay in the intensive care unit (median two days, p = 0.4), or mortality (324 deaths, moderate trauma, p = 0.13; major trauma, p = 0.8). CONCLUSION: Long prehospital times in the rural environment were not associated with differences in mortality or length of stay in moderately and severely injured patients in the west of Scotland. This may lend support to a policy of rationalization of trauma services in Scotland.

Rapid sequence intubation of trauma patients in Scotland.

BACKGROUND: Endotracheal intubation remains the gold standard for trauma airway management. Rapid sequence intubation (RSI) has traditionally been performed by anesthesiologists but increasingly, emergency physicians are also undertaking RSI. We aimed to compare success and complication rates for trauma intubations for the two specialties. METHODS: Two year, prospective multi-center descriptive study of trauma RSI in seven Scottish urban emergency departments. RESULTS: 439 trauma patients were identified, including 233 RSIs. Patients intubated by emergency physicians had a higher median ISS (p < 0.001) and lower median RTS (p < 0.001) compared with anesthesiologists. For RSI, anesthesiologists had more grade I & II views at laryngoscopy (p = 0.051) and more successful first attempt intubations (p = 0.034) but there was no difference in the number of patients suffering complications (emergency physicians 10.0%, anesthesiologists 10.6%). CONCLUSION: There is no significant difference in complication rates for trauma RSI between emergency physicians and anesthesiologists in Scottish urban centers. A collaborative approach to the critical trauma airway is vital. Emergency physicians should consult with senior anesthesiologists before RSI when intubation is predicted to be difficult.

Patients with a head injury who "talk and die" in the 1990s.

BACKGROUND: Patients who "talk and die" after head injury may represent a group who suffer delayed and therefore potentially preventable complications after injury. We have compared the clinical and pathologic features of patients who talk and die with those who "talk and live" after head injury. METHODS: Data collected prospectively by the Scottish Trauma Audit Group were used to identify patients with a head injury and classify them according to verbal response at admission to hospital. All "talking" patients in the catchment area of a regional neurosurgical center were selected and those who died were compared with those who survived. RESULTS: Seven hundred eighty-nine talking patients were identified. Seven hundred twenty-seven patients survived and 62 died. Patients who talked and died were older, had more severe extracranial injuries, had lower consciousness levels, and reached theater more quickly than those who talked and lived. Thirty-one of the patients that died had extra-axial hematomas. CONCLUSION: Even with increased availability of computed tomographic scanning, some patients still talk and die after head injury.