Prehospital tourniquet use: An evaluation of community application and outcome.

BACKGROUND: There is substantial investment in layperson and first responder training involving tourniquet use for hemorrhage control. Little is known however about prehospital tourniquet application, field conversion, or outcomes in the civilian setting. We describe the experience of a metropolitan region with prehospital tourniquet application. METHODS: We conducted a retrospective cohort study characterizing prehospital tourniquet use treated by emergency medical services (EMS) in King County, Washington, from January 2018 to June 2019. Emergency medical services and hospital records were abstracted for demographics, injury mechanism, tourniquet details, clinical care, and outcomes. We evaluated the incidence of tourniquet application, who applied the device (EMS, law enforcement, or layperson), and subsequent course. RESULTS: A total of 168 patients received tourniquet application, an incidence of 5.1 per 100,000 person-years and 3.48 per 1,000 EMS responses for trauma. Tourniquets were applied for penetrating trauma (64%), blunt trauma (30%), and bleeding ateriovenous fistulas (7%). A subset was critically ill: 13% had systolic blood pressures of <90 mm Hg, 8% had Glasgow Coma Scale score of <13, and 3% had cardiac arrest. Among initial applications, 48% were placed by law enforcement, 33% by laypersons, and 18% by EMS. Among tourniquets applied by layperson or law enforcement (n = 137), EMS relied solely on the original tourniquet in 45% (n = 61), placed a second tourniquet in 20% (n = 28), and removed the tourniquet without replacement in 35% (n = 48). Overall, 24% required massive transfusion, 59% underwent urgent surgery, and 21% required vascular surgery. Mortality was 3% (n = 4). At hospital discharge, the tourniquet limb was fully functional in 81%, partially functional in 10%, and nonfunctional in 9%; decreased function was not attributed to tourniquet application. CONCLUSION: The high rate of application, need for urgent hospital intervention in a subset, and low incidence of apparent complication suggest that efforts to increase access and early tourniquet use can provide public health benefit. LEVEL OF EVIDENCE: Therapeutic, level IV.

Increased Use of Prehospital Tourniquet and Patient Survival: Los Angeles Countywide Study.

BACKGROUND: Recent trends in prehospital tourniquet use remain underreported. In addition, the impact of prehospital tourniquet use on patient survival has not been evaluated in a population-level study. We hypothesized that prehospital tourniquets were used more frequently in Los Angeles County and their use was associated with improved patient survival. STUDY DESIGN: This is a retrospective cohort study using a database maintained by the Los Angeles County Emergency Medical Services Agency. We included patients who sustained extremity vascular injuries between October 2015 and July 2019. Patients were divided into the following study groups: prehospital tourniquet and no-tourniquet group. Our primary end point was in-hospital mortality. The secondary outcomes included 4- and 24-hour transfusion requirements and delayed amputation. RESULTS: A total of 944 patients met our inclusion criteria. Of those, 97 patients (10.3%) had prehospital tourniquets placed. The rate of tourniquet use increased linearly throughout our study period (goodness of fit, p = 0.014). In multivariable analysis, prehospital tourniquet use was significantly associated with improved mortality (adjusted odds ratio 0.32; 95% CI, 0.16 to 0.85; p = 0.032). Similarly, transfusion requirements were significantly lower within 4 hours (regression coefficient -547.76; 95% CI, -762.73 to -283.49; p < 0.001) and 24 hours (regression coefficient -1,389.82; 95% CI, -1,824.88 to -920.97; p < 0.001). There was no significant difference in delayed amputation rates (adjusted odds ratio 1.07; 95% CI, 0.21 to 10.88; p < 0.097). CONCLUSIONS: Prehospital tourniquet use has been on the rise in Los Angeles County. Our results suggest that the use of prehospital tourniquets for extremity vascular injuries is associated with improved patient survival and decreased blood transfusion requirements, without an increase in delayed amputations.

Increased staple loading pressures and reduced staple heights in laparoscopic sleeve gastrectomy reduce intraoperative bleeding.

BACKGROUND: In laparoscopic sleeve gastrectomy, tissue thickness and closed staple height of the staple cartridge determine the pressure applied to the tissue. Prior studies have suggested 8 g/mm2 to be ideal to minimize leaks or bleeding. METHODS: We evaluated the relationship between staple loading pressure applied to gastric tissue and bleeding rate prospectively with a novel tissue measuring device and video-recorded operative findings for 116 patients undergoing laparoscopic sleeve gastrectomy performed by 2 surgeons at a single institution. Stapling protocol 1 was used for 64 cases, defined as standard practice, typically using green-blue-blue-blue Ethicon staple cartridges. Stapling protocol 2 was defined as blue-blue-white-white or gold-blue-white-white. RESULTS: Tissue thickness measurements from 39 cases and staple load selection showed that surgeons preferred a median staple loading pressure of 15 g/mm2. Tissue thickness measurements at 15 g/mm2 had a mean of 1.86 mm at the antrum, 1.71 mm at the body, and 1.15 mm at the fundus, all significantly thinner than tissue thickness at 8 g/mm2. For each 10 g/mm2 increase in minimum pressure and maximum pressure value within each cartridge zone, there was a reduction in bleeding rate by 59.8% and 38.7%, respectively. Compared with stapling protocol 1, stapling protocol 2 had a lower intraoperative bleeding rate (90.2% vs 70.7%; P < .0001), usage of preventive hemostatic techniques (100% vs 10%; P < .0001), and hemostatic treatments (66% vs 46%; P = .04). In the 30-day postoperative period, there was 1 bleed in stapling protocol 1; there were no leaks. CONCLUSION: Our data suggest using shorter closed staple heights to exert higher staple loading pressures decreases intraoperative bleeding rates in laparoscopic sleeve gastrectomy.

A Randomized Trial Comparing Short versus Prolonged Hemostasis with Rescue Recanalization by Ipsilateral Ulnar Artery Compression: Impact on Radial Artery Occlusion-The RESCUE-RAO Trial.

BACKGROUND: Despite the enormous benefits of radial access, this route is associated with a risk of radial artery occlusion (RAO). OBJECTIVE: We compared the incidence of RAO in patients undergoing transradial coronary angiography and intervention after short versus prolonged hemostasis protocol. Also we assessed the efficacy of rescue 1-hour ipsilateral ulnar artery compression if RAO was observed after hemostasis. Material and Methods. Patients referred for elective transradial coronary procedures were eligible. After 6 F radial sheath removal, patients were randomized to short (3 hours) (n = 495) or prolonged (8 hours) (n = 503) hemostasis and a simple bandage was placed over the puncture site. After hemostasis was completed, oximetry plethysmography was used to assess the patency of the radial artery. RESULTS: One thousand patients were randomized. Baseline characteristics were similar between both groups with average age 61.4 ± 9.4 years (71% male) and PCI performed on half of the patients. The RAO rate immediately after hemostasis was 3.2% in the short hemostasis group and 10.1% in the prolonged group (p < 0.001). Rescue recanalization was successful only in the short group in 56.2% (11/19); at hospital discharge, RAO rates were 1.4% in the short group and 10.1% in the prolonged group (p < 0.001). CONCLUSION: Shorter hemostasis was associated with significantly less RAO compared to prolonged hemostasis. Rescue radial artery recanalization was effective in > 50%, but only in the short hemostasis group.

Gastrointestinal Bleeding in Patients With Coronavirus Disease 2019: A Matched Case-Control Study.

INTRODUCTION: Although current literature has addressed gastrointestinal presentations including nausea, vomiting, diarrhea, abnormal liver chemistries, and hyperlipasemia as possible coronavirus disease 2019 (COVID-19) manifestations, the risk and type of gastrointestinal bleeding (GIB) in this population is not well characterized. METHODS: This is a matched case-control (1:2) study with 41 cases of GIB (31 upper and 10 lower) in patients with COVID-19 and 82 matched controls of patients with COVID-19 without GIB. The primary objective was to characterize bleeding etiologies, and our secondary aim was to discuss outcomes and therapeutic approaches. RESULTS: There was no difference in the presenting symptoms of the cases and controls, and no difference in severity of COVID-19 manifestations (P > 0.05) was observed. Ten (32%) patients with upper GIB underwent esophagogastroduodenoscopy and 5 (50%) patients with lower GIBs underwent flexible sigmoidoscopy or colonoscopy. The most common upper and lower GIB etiologies were gastric or duodenal ulcers (80%) and rectal ulcers related to rectal tubes (60%), respectively. Four of the esophagogastroduodenoscopies resulted in therapeutic interventions, and the 3 patients with rectal ulcers were referred to colorectal surgery for rectal packing. Successful hemostasis was achieved in all 7 cases that required interventions. Transfusion requirements between patients who underwent endoscopic therapy and those who were conservatively managed were not significantly different. Anticoagulation and rectal tube usage trended toward being a risk factor for GIB, although it did not reach statistical significance. DISCUSSION: In COVID-19 patients with GIB, compared with matched controls of COVID-19 patients without GIB, there seemed to be no difference in initial presenting symptoms. Of those with upper and lower GIB, the most common etiology was peptic ulcer disease and rectal ulcers from rectal tubes, respectively. Conservative management seems to be a reasonable initial approach in managing these complex cases, but larger studies are needed to guide management.

Gastrointestinal bleeding in patients with pancreatic cancer: Causes and haemostatic treatments.

BACKGROUND: Gastrointestinal bleeding is a rare but severe complication of pancreatic ductal adenocarcinoma. OBJECTIVE: The purpose of this study was to describe the causes and treatments of non-postoperative gastrointestinal bleeding in patients with pancreatic ductal adenocarcinoma, and explore the parameters associated with therapeutic effectiveness. METHODS: This was a single-centre observational retrospective study (2000-2017) with data collected from the prospectively coded diagnostic hospital's database system including patients with pancreatic ductal adenocarcinoma who had a gastrointestinal bleeding episode. Effectiveness of haemostatic treatment was assessed according to transfusion requirements and immediate and long-term haemostatic efficacy; the latter defined as no bleeding recurrence. RESULTS: The population included 72 patients with pancreatic ductal adenocarcinoma who had 94 episodes of gastrointestinal bleeding. The main causes of gastrointestinal bleeding were gastroduodenal tumour invasion (56.4%) and oesophageal variceal bleeding due to left-sided portal hypertension (19.1%). In cases of gastrointestinal bleeding caused by tumour invasion, the main treatment was therapeutic endoscopy (41.5%). Among patients who had gastrointestinal bleeding by tumour invasion treated by endoscopy or radiation therapy, haemostatic immediate efficacy rates were 70.6% and 100%, respectively. Bleeding recurrence rates were 35.3% and 25.0%, for patients treated by endoscopy or radiation therapy, respectively, for a first episode of gastrointestinal bleeding by tumour invasion. Transfusion requirements, before and after treatment, were not different in patients treated by haemostatic radiation therapy for gastrointestinal bleeding by tumour invasion compared to other treatments (odds ratio 0.3, 95% CI (0.06-1.59); p = 0.16). The median survival after all-cause gastrointestinal bleeding was 2.72 months (1.43-4.01). CONCLUSION: Gastroduodenal tumour invasion was the main cause of gastrointestinal bleeding in patients with pancreatic ductal adenocarcinoma; haemostatic radiation therapy is a potential interesting option for gastrointestinal bleeding treatment in this context.

Epidemiology of Hemostatic Transfusions in Children Supported by Extracorporeal Membrane Oxygenation.

OBJECTIVE: To evaluate the epidemiology of hemostatic transfusions (plasma, platelet, and cryoprecipitate) in children supported by extracorporeal membrane oxygenation. DESIGN: Secondary analysis of a large observational cohort study. SETTING: Eight pediatric institutions within the Eunice Kennedy Shriver National Institute of Child Health and Human Development's Collaborative Pediatric Critical Care Research Network. PATIENTS: Critically ill children supported by extracorporeal membrane oxygenation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Extracorporeal membrane oxygenation was used in the care of 514 consecutive children. Platelets were transfused on 68% of extracorporeal membrane oxygenation days, plasma on 34% of the days on extracorporeal membrane oxygenation, and cryoprecipitate on 14%. Only 24% of the days on extracorporeal membrane oxygenation were free of any hemostatic transfusions. Daily platelet transfusion dose was independently associated with chest tube output (p < 0.001), other bleeding requiring RBC transfusion (p = 0.03), and daily set platelet goal (p = 0.009), but not with total platelet count (p = 0.75). Daily plasma transfusion dose was independently associated with chest tube output (p < 0.001), other bleeding requiring RBC transfusion (p = 0.01), activated clotting time (p = 0.001), and antithrombin levels (p = 0.02), but not with international normalized ratio (p = 0.99) or activated partial thromboplastin time (p = 0.29). Daily cryoprecipitate transfusion dose was independently associated with younger age (p = 0.009), but not with chest tube bleeding (p = 0.18), other bleeding requiring RBC transfusion (p = 0.75), fibrinogen level (p = 0.67), or daily fibrinogen goal (p = 0.81). CONCLUSIONS: Platelets were transfused on two third of the days on extracorporeal membrane oxygenation, plasma on one third, and cryoprecipitate on one sixth of the days. Although most hemostatic transfusions were independently associated with bleeding, they were not independently associated with the majority of hemostatic testing. Further studies are warranted to evaluate the appropriateness of these transfusion strategies.

Validation of a Machine Learning Model That Outperforms Clinical Risk Scoring Systems for Upper Gastrointestinal Bleeding.

BACKGROUND & AIMS: Scoring systems are suboptimal for determining risk in patients with upper gastrointestinal bleeding (UGIB); these might be improved by a machine learning model. We used machine learning to develop a model to calculate the risk of hospital-based intervention or death in patients with UGIB and compared its performance with other scoring systems. METHODS: We analyzed data collected from consecutive unselected patients with UGIB from medical centers in 4 countries (the United States, Scotland, England, and Denmark; n = 1958) from March 2014 through March 2015. We used the data to derive and internally validate a gradient-boosting machine learning model to identify patients who met a composite endpoint of hospital-based intervention (transfusion or hemostatic intervention) or death within 30 days. We compared the performance of the machine learning prediction model with validated pre-endoscopic clinical risk scoring systems (the Glasgow-Blatchford score [GBS], admission Rockall score, and AIMS65). We externally validated the machine learning model using data from 2 Asia-Pacific sites (Singapore and New Zealand; n = 399). Performance was measured by area under receiver operating characteristic curve (AUC) analysis. RESULTS: The machine learning model identified patients who met the composite endpoint with an AUC of 0.91 in the internal validation set; the clinical scoring systems identified patients who met the composite endpoint with AUC values of 0.88 for the GBS (P = .001), 0.73 for Rockall score (P < .001), and 0.78 for AIMS65 score (P < .001). In the external validation cohort, the machine learning model identified patients who met the composite endpoint with an AUC of 0.90, the GBS with an AUC of 0.87 (P = .004), the Rockall score with an AUC of 0.66 (P < .001), and the AIMS65 with an AUC of 0.64 (P < .001). At cutoff scores at which the machine learning model and GBS identified patients who met the composite endpoint with 100% sensitivity, the specificity values were 26% with the machine learning model versus 12% with GBS (P < .001). CONCLUSIONS: We developed a machine learning model that identifies patients with UGIB who met a composite endpoint of hospital-based intervention or death within 30 days with a greater AUC and higher levels of specificity, at 100% sensitivity, than validated clinical risk scoring systems. This model could increase identification of low-risk patients who can be safely discharged from the emergency department for outpatient management.

Manejo de las epistaxis graves y/o refractarias / Management of severe and/or refractory epistaxis

Introducción y objetivos: El objetivo fue determinar los resultados del tratamiento de las epistaxis graves y/o refractarias que requirieron ingreso hospitalario. Además se compararon los resultados del tratamiento mediante ligadura arterial o embolización. Material y método: Se incluyeron de forma prospectiva 63 pacientes con epistaxis grave y/o refractaria que requirieron ingreso hospitalario entre agosto de 2014 y diciembre de 2016. Resultados: En 11 pacientes (17%) se realizó embolización, 5 (8%) fueron intervenidos mediante endoscopia y en los 47 restantes (75%) se realizó tratamiento conservador. La edad media de los pacientes en los que las medidas conservadoras fueron suficientes fue de 72 años, mientras que la edad de aquellos tratados con embolización fue de 71 años y de los que fueron intervenidos quirúrgicamente fue de 53 años. En los pacientes sometidos a tratamiento conservador o a cirugía la estancia media fue de 6 días, frente a 9 días en aquellos en los que se realizó embolización. Un paciente sufrió un ictus hemisférico tras la embolización. No se observaron complicaciones posquirúrgicas. Conclusiones: La mayoría de los pacientes con epistaxis graves y/o refractarias se resuelven mediante taponamiento convencional. El tratamiento mediante ligadura arterial está asociado a una disminución de la estancia hospitalaria, sin observarse complicaciones graves. Es aconsejable disponer de todas las opciones terapéuticas posibles para lo cual la presencia de radiólogos intervencionistas y cirujanos experimentados es fundamental para evitar complicaciones y decidir el tratamiento a realizar de forma individual en cada paciente

Objective: The objective was to determine the results of the treatment of severe and/or refractory epistaxis requiring hospital admission. In addition, the results of arterial ligation versus embolization were compared. Material and method: Sixty-three patients with severe and/or refractory epistaxis requiring hospital admission between August 2014 and December 2016 were included prospectively. Results: Eleven patients (17%) underwent embolization, 5 (8%) endoscopy ligation and the remaining 47 (75%) underwent conservative treatment with tamponade. The mean age of the patients in which conservative measures were sufficient was 72 years, while the age of those treated with embolization was 71 years and of those who underwent surgery was 53 years. For the patients who underwent conservative treatment or surgery, the average stay was 6 days, compared to 9 days for those who underwent embolization. One patient suffered a hemispheric stroke after embolization. No post-surgical complications were observed. Conclusions: Most cases of severe and/or refractory epistaxis are resolved by conventional tamponade. Endoscopy ligation is associated with a decrease in hospital stay, without serious complications. It is advisable to have all the possible therapeutic options available, for which the presence of interventional radiologists and experienced surgeons is essential to avoid complications and decide the treatment to be performed individually for each patient

The effect of hemorrhage control adjuncts on outcome in severe pelvic fracture: A multi-institutional study.

BACKGROUND: Hemodynamically unstable patients with severe pelvic fracture are a significant challenge to trauma surgeons and have high mortality. Significant variability across institutions in hemorrhage control adjuncts used to quell pelvic bleeding has been demonstrated. However, the effect of these methods on time to definitive bleeding control, type of resuscitation given, and outcomes remains unknown. We sought to elucidate those effects. METHODS: This was a multicenter retrospective review of severe pelvic fracture patients in shock between 2011 and 2016. Shock was defined as systolic blood pressure less than 90 mm Hg, heart rate greater than 120 beats per minute, or base deficit less than -5. Definitive bleeding control was defined as time to surgical control in the operating room or embolization by interventional radiology. Significance level was at p less than 0.05. RESULTS: A total of 279 severe pelvic fracture patients with shock on admission from 12 trauma centers were included. The cohort was primarily male (62%) with median (interquartile range) age of 40 years (28-54 years), Injury Severity Score of 38 (29-50), and Glasgow Coma Scale score of 13 (3-15). Overall mortality was 32%. The most common adjunct used was pelvic binder (50%) followed by no adjunct (30.5%); least common was resuscitative balloon occlusion of the aorta (REBOA) (2.5%). Preperitoneal packing alone and REBOA alone/with other adjunct(s) resulted in the fastest times to operating room/interventional radiology but also had the highest blood utilization and mortality rates. Resuscitative balloon occlusion of the aorta was most often used along with pelvic binder (6 of 13; 46%). CONCLUSION: Marked variation in management of severe pelvic fracture patients in shock indicates the need for a standardized approach to maximize outcomes and minimize transfusion requirements. The use of preperitoneal packing and/or REBOA yielded fastest times to definitive bleeding control. However, REBOA continues to be infrequently used. Future prospective analysis of this combination needs further validation in patients with severe pelvic hemorrhage. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Sex-based differences in transfusion need after severe injury: Findings of the PROPPR study.

BACKGROUND: Women are underrepresented in trauma research, and aggregated results of clinical trials may mask effects that differ by sex. It is unclear whether women respond differently to severe hemorrhage compared with men. We sought to evaluate sex-based differences in outcomes after severe trauma with hemorrhage. METHODS: We performed a secondary analysis of the Pragmatic Randomized Optimal Platelet and Plasma Ratios trial. Trauma patients predicted to require massive transfusion were randomized to a 1:1:1 vs 1:1:2 plasma to platelet to red blood cell transfusion ratio. Analysis was performed according to sex, controlling for clinical characteristics and transfusion arm. RESULTS: A total of 134 women and 546 men were analyzed. In multivariable analysis, there was no difference in mortality at 24 hours (hazard ratio for women 0.64, 95% confidence interval 0.34-1.23, P = .18) or in time to hemostasis (hazard ratio 1.10, 95% confidence interval 0.84-1.42, P = .49) by sex. We observed no difference between sexes in volume of blood products transfused during active hemorrhage. However, after anatomic hemostasis, women received lower volumes of all products, with a 38% reduction in fresh frozen plasma (mean ratio 0.62 (95% confidence interval 0.43-0.89, P = .01), 49% reduction in platelets (mean ratio 0.51, 95% confidence interval 0.33-0.79, P < .01) and 49% reduction in volume of red blood cells (mean ratio 0.51, 95% confidence interval 0.33-0.79, P < .01). CONCLUSION: Mortality and time to hemostasis of trauma patients with hemorrhage did not differ by sex. Although there was no difference in transfusion requirement during active hemorrhage, once hemostasis was achieved, women received fewer units of all blood products than men. Further research is required to determine whether women exhibit differences in coagulation during and after severe traumatic hemorrhage.

Management of severe and/or refractory epistaxis. / Manejo de las epistaxis graves y/o refractarias.

OBJECTIVE: The objective was to determine the results of the treatment of severe and/or refractory epistaxis requiring hospital admission. In addition, the results of arterial ligation versus embolization were compared. MATERIAL AND METHOD: Sixty-three patients with severe and/or refractory epistaxis requiring hospital admission between August 2014 and December 2016 were included prospectively. RESULTS: Eleven patients (17%) underwent embolization, 5 (8%) endoscopy ligation and the remaining 47 (75%) underwent conservative treatment with tamponade. The mean age of the patients in which conservative measures were sufficient was 72 years, while the age of those treated with embolization was 71 years and of those who underwent surgery was 53 years. For the patients who underwent conservative treatment or surgery, the average stay was 6 days, compared to 9 days for those who underwent embolization. One patient suffered a hemispheric stroke after embolization. No post-surgical complications were observed. CONCLUSIONS: Most cases of severe and/or refractory epistaxis are resolved by conventional tamponade. Endoscopy ligation is associated with a decrease in hospital stay, without serious complications. It is advisable to have all the possible therapeutic options available, for which the presence of interventional radiologists and experienced surgeons is essential to avoid complications and decide the treatment to be performed individually for each patient.

Resuscitative Endovascular Balloon Occlusion of the Aorta: Assessing Need in an Urban Trauma Center.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged as a bridge to definitive hemostasis in select patients with noncompressible torso hemorrhage. The number of patients who might benefit from this procedure, however, remains incompletely defined. We hypothesized that we could quantify the number of patients presenting to our center over a 2-year period who may have benefited from REBOA. METHODS: All patients presenting to our trauma center from 2014 to 2015 were included. Potential REBOA patients were identified based on anatomic injuries. We used ICD-9 codes to identify REBOA-amenable injury patterns and physiology. We excluded patients with injuries contraindicating REBOA. We then used chart review by two REBOA-experienced independent reviewers to assess each potential REBOA candidate, evaluate the accuracy of our algorithm, and to identify a cohort of confirmed REBOA candidates. RESULTS: Four thousand eight hundred eighteen patients were included of which 666 had injuries potentially amenable to REBOA. Three hundred thirty-five patients were hemodynamically unstable, and 309 patients had contraindications to REBOA. Sixty-four patients had both injury patterns and physiology amenable to REBOA with no contraindications, and these patients were identified as potential REBOA candidates. Of these, detailed independent two physician chart review identified 29 patients (45%) as confirmed REBOA candidates (interrater reliability kappa = 0.94, P < 0.001). CONCLUSIONS: Our database query identified patients with indications for REBOA but overestimated the number of REBOA candidates. To accurately quantify the REBOA candidate population at a given center, an algorithm to identify potential patients should be combined with chart review. STUDY TYPE: Therapeutic study, level V.

Modified Robert Jones bandage can not reduce invisible blood loss after total knee arthroplasty: a randomized-controlled trial.

INTRODUCTION: To compare the efficacy and safety of modified Robert Jones bandage (MRJB) and non-compressive dressing (NCD) on reducing invisible blood loss (IBL) after total knee arthroplasty (TKA). MATERIALS AND METHODS: Eighty patients who underwent unilateral TKA were randomly assigned into two groups: MRJB and NCD groups. Pre- and post-operative hematocrit levels, amount of drained blood and transfused blood were measured and calculated into IBL. Pain score, amount of morphine usage, range of motion (ROM) at discharge, blood transfusion rate, and complications were also recorded and compared between both groups. RESULTS: There was no significant difference in the mean IBL between MRJB (221.2 ± 233.3 ml) and NCD groups (158.5 ± 186.7 ml) (p = 0.219). Post-operative pain score at rest and during ambulation, amount of morphine usage, ROM at discharge, blood transfusion rate, and complications were also similar between two groups. CONCLUSIONS: This study cannot determine the benefit of MRJB over NCD. The use of MRJB may not be necessary after primary TKA.

Rotational thromboelastometry thresholds for patients at risk for massive transfusion.

BACKGROUND: Goal-directed hemostatic resuscitation based on thrombelastography has a survival benefit compared to conventional coagulation assays. While thrombelastography transfusion thresholds for patients at risk for massive transfusion (MT) have been defined, similar cutoffs do not exist for the other commonly used viscoelastic assay, rotational thromboelastometry (ROTEM). The purpose of this study was to develop ROTEM blood product thresholds in patients at risk for MT. METHODS: ROTEM was assessed in trauma activation patients admitted from 2010 to 2016 (n = 222). Receiver operating characteristic curve analyses were performed to test the predictive performance of ROTEM measurements in patients requiring MT. The Youden Index defined optimal thresholds for ROTEM-based resuscitation. RESULTS: Patients who required MT (n = 37, 17%) were more severely injured. EXTEM clotting time (CT) was longer in patients with MT compared to non-MT (87 versus 64 s, P < 0.0001). EXTEM angle was shallower in MT patients compared to non-MT (54° versus 69°, P < 0.0001). Clot amplitude after 10 min (CA10) was less in MT compared to non-MT patients (30.5 versus 50 mm, P < 0.0001). Clot lysis index 60 min (CLI60) was lower in patients who had MT than non-MT (47 versus 94%, P = 0.0006). EXTEM CT yielded an area under the receiver operating characteristic curve (AUROC) = 0.7116 and a cut point of >78.5 s. EXTEM angle had an AUROC = 0.865 and a cut point of <64.5°. EXTEM CA10 had an AUROC = 0.858, with a cut point of <40.5 mm. CLI60 had an AUROC = 0.6788 with a cut point at <74%. CONCLUSIONS: We have identified ROTEM thresholds for transfusion of blood components in severely injured patients requiring an MT. Based on our analysis, we propose plasma transfusion for EXTEM CT > 78.5 s, fibrinogen for angle <64.5°, platelet transfusion for CA10 < 40.5 mm, and antifibrinolytics for CLI60 < 74%.

The evolution of pediatric transfusion practice during combat operations 2001-2013.

BACKGROUND: Hemostatic resuscitation principles have significantly changed adult trauma resuscitation over the past decade. Practice patterns in pediatric resuscitation likely have changed as well; however, this evolution has not been quantified. We evaluated pediatric resuscitation practices over time within a combat trauma system. METHODS: The Department of Defense Trauma Registry was queried from 2001 to 2013 for pediatric patients (<18 years). Patients with burns, drowning, and missing injury severity score were excluded. Volumes of crystalloid, packed red blood cells (PRBC), whole blood, plasma, and platelets (PLT) given in the first 24 hours were calculated per kilogram body weight. Tranexamic acid use was also determined. Patients were divided into Early (2001-2005) and Late (2006-2013) cohorts, and subgroups of transfused (TX+) and massively transfused (MT+) patients were created. Intensive care unit and hospital length of stay and 24-hour and in-hospital mortality rates were compared. RESULTS: A total of 4,358 patients met inclusion criteria. Comparing Early versus Late, injuries from explosions, isolated or predominant head injuries, and injury severity score all increased. The proportion of TX+ patients also increased significantly (13.6% vs 37.4%, p < 0.001) as did the number of MT+ patients (2.1% vs 15.5%, p < 0.001). Transfusion of high plasma:RBC and PLT:RBC ratios increased in both the TX+ and MT+ subgroups, although overall, PLT and whole blood use was low. After adjusting for differences between groups, the odds of death was no different Early versus Late but decreased significantly in the MT+ patients with time as a continuous variable. CONCLUSION: Transfusion practice in pediatric combat casualty care shifted toward a more hemostatic approach over time. All-cause mortality was low and remained stable overall and even decreased in MT+ patients despite more injuries due to explosions, more head injuries, and greater injury severity. However, further study is required to determine the optimal resuscitation practices in critically injured children. LEVEL OF EVIDENCE: Epidemiologic study, level IV.

Treatment disparities in the management of epistaxis in United States emergency departments.

OBJECTIVES: There is limited data on epistaxis presentation and management patterns in U.S. emergency departments (EDs). We aim to characterize patients who present to the ED with epistaxis and identify factors associated with nasal-packing use. STUDY DESIGN: Retrospective review of Nationwide Emergency Department Sample (NEDS) from 2009 to 2011. METHODS: NEDS was queried for patient visits with a primary diagnosis of epistaxis (International Classification of Diseases, Ninth Revision, Clinical Modification code 784.7). Patient demographics, comorbidities, and hospital characteristics were obtained. Predictors of nasal packing were determined by multivariable logistic regression. RESULTS: There were 1,234,267 ED visits for epistaxis. The highest proportion of patients were seen in the winter (37.2%) at nontrauma hospitals (76.9%), and were discharged home (95.5%). Fifteen percent of patients were on long-term anticoagulation, 33% had hypertension, and 0.9% had a coagulopathy. Nasal packing was utilized in 243,268 patients (19.7%). Predictors strongly associated with nasal packing included lower socioeconomic quartile (odds ratio [OR] 1.30, 95% confidence interval [CI] = 1.10-1.53), hospital located in the geographic South (OR 1.62, CI = 1.12-2.34) and Midwest (OR 1.85, P < 0.0001), and nontrauma hospital (OR 1.56, CI = 1.19-2.05). Other factors included long-term anticoagulation (OR 1.21, CI = 1.10-1.33), winter season (OR 1.20, CI = 1.12-1.23), male gender (OR 1.14, CI = 1.10-1.17), and older age (OR 1.01, CI = 1.01-1.02). Mean ED charge was greater for patients who were packed ($1,473 vs. $1,048, P < 0.0001). CONCLUSION: Several factors, including lower socioeconomic status, geographic location, and nontrauma hospital designation, predict use of nasal packing. These results raise concerns about potential treatment disparities that may result in increased patient morbidity and costs. LEVEL OF EVIDENCE: 2C. Laryngoscope, 128:356-362, 2018.

Use of Hemostatic Nasal Plugs in Emergency Medical Services in the Netherlands: A Prospective Study of 33 Cases.

BACKGROUND: Epistaxis is a common medical emergency with possible life-threatening complications. In the prehospital setting, epistaxis can be treated with nasal tampons. HemCon® Nasal Plug is a nasal tampon impregnated with oxidized cellulose, which has hemostatic properties. OBJECTIVE: The objective of this study was to determine the effectiveness and usability of HemCon Nasal Plugs in the treatment of severe epistaxis in the prehospital setting. METHODS: From June 2012 to December 2014, all ambulances of two emergency medical services in the Netherlands were equipped with HemCon Nasal Plugs. The plug was used according to protocol; if conventional treatment failed to control severe epistaxis or if conventional treatment was unlikely to achieve hemostasis. The ambulance personnel filled in an evaluation form after each use. RESULTS: A total of 33 patients were treated with HemCon Nasal Plugs. Twenty-four patients were taking anticoagulants or suffered from a clotting disorder. The cause of epistaxis was idiopathic in the majority of the patients. Inserting HemCon Nasal Plugs resulted in cessation of epistaxis in 25/33 patients and resulted in reduction of epistaxis in 4/33 patients. HemCon Nasal Plugs failed to control epistaxis in 4/33 patients, possible due to an unreachable site of bleeding. CONCLUSION: This study demonstrated that HemCon Nasal Plug is an effective adjunct in the prehospital treatment of severe and uncontrolled epistaxis.

The incidence of life threatening iatrogenic vessel injury following closed or open reduction and internal fixation of intertrochanteric femoral factures.

AIM OF THE STUDY: Bleeding due to a vascular injury is a possible life-threatening complication of intertrochanteric femoral fracture internal fixation. Our goals were to find the current incidence of these events, and to describe the reasons, the presentation, and the treatment options. METHOD: We conducted a retrospective record review of 1,469 patients who were operated upon at our institution due to AO31A femoral fractures from 2011 through 2015 and were treated with closed reduction and internal fixation. RESULTS: Three patients were diagnosed with iatrogenic vascular bleeding, which constitute an incidence of 0.2%. The vascular injuries were detected as deep femoral artery bleeding adjacent to the distal locking screws. The patients were treated with ultrasound guided thrombin injection, endovascular coil embolization or with no endovascular intervention. DISCUSSION: Vascular injuries are caused mainly by perforating a vessel while drilling the distal locking screw holes. A high level of suspicion and immediate imaging work-up are mandatory. CONCLUSIONS: A vascular injury due to internal fixation of a proximal AO31A femoral fracture is a rare complication.