The Impact of Prehospital Tranexamic Acid on Blood Coagulation in Trauma Patients.

BACKGROUND: There is limited data on prehospital administration of tranexamic acid (TXA) in civilian trauma. The aim of this study was to evaluate changes in coagulation after severe trauma from on-scene to the hospital after TXA application in comparison to a previous study without TXA. METHODS: The study protocol was registered at ClinicalTrials.gov (NCT02354885). A prospective, multicenter, observational study investigating coagulation status in 70 trauma patients receiving TXA (1 g intravenously) on-scene versus a control group of 38 patients previously published without TXA. To account for potential differences in patient and trauma epidemiology, crystalloid and colloidal resuscitation fluid, 2 propensity score matched groups (n = 24 per group) were created. Measurements included ROTEM, standard coagulation tests and blood gas analyses on-scene and emergency department admission. Presented values are mean and [standard deviation], and difference in means and 95% confidence intervals. RESULTS: Patient epidemiology was not different between groups. Coagulation assays on-scene were comparable between the TXA and C. Prehospital hyperfibrinolysis was blunted in all 4 patients in the TXA group. Viscoelastic FIBTEM maximum clot firmness (MCF), representing functional fibrinogen levels, did not change from on-scene to the emergency department in the TXA group, whereas MCF decreased -3.7 [1.8] mm in the control group. Decrease of MCF was significantly reduced in the TXA group in EXTEM by 9.2 (7.2-11.2) mm (P < .001) and INTEM by 6.8 (4.7-9.0) mm (P < .001) in favor of the TXA group. Production of fibrinogen fragments (represented by D-dimers) was significantly lower in the TXA group compared to group C. CONCLUSIONS: Early prehospital administration of TXA leads to clot stabilization and a reduction of fibrinolytic activity, causing a decrease in fibrin degradation products buildup (D-dimer).

Central nervous system microbleeds in the acute phase are associated with structural integrity by DTI one year after mild traumatic brain injury: A longitudinal study.

INTRODUCTION: Several imaging modalities are under investigation to unravel the pathophysiological mystery of delayed performance deficits in patients after mild traumatic brain injury (mTBI). Although both imaging and neuropsychological studies have been conducted, only few data on longitudinal correlations of diffusion tensor imaging (DTI), susceptibility weighted imaging (SWI) and extensive neuropsychological testing exist. METHODS: MRI with T1- and T2-weighted, SWI and DTI sequences at baseline and 12 months of 30 mTBI patients were compared with 20 healthy controls. Multiparametric assessment included neuropsychological testing of cognitive performance and post-concussion syndrome (PCS) at baseline, 3 and 12 months post-injury. Data analysis encompassed assessment of cerebral microbleeds (Mb) in SWI, tract-based spatial statistics (TBSS) and voxel-based morphometry (VBM) of DTI (VBM-DTI). Imaging markers were correlated with neuropsychological testing to evaluate sensitivity to cognitive performance and post-concussive symptoms. RESULTS: Patients with Mb in SWI in the acute phase showed worse performance in several cognitive tests at baseline and in the follow-ups during the chronic phase and higher symptom severity in the post concussion symptom scale (PCSS) at twelve months post-injury. In the acute phase there was no statistical difference in structural integrity as measured with DTI between mTBI patients and healthy controls. At twelve months post-injury, loss of structural integrity in mTBI patients was found in nearly all DTI indices compared to healthy controls. CONCLUSIONS: Presence of Mb detected by SWI was associated with worse cognitive outcome and persistent PCS in mTBI patients, while DTI did not prove to predict neuropsychological outcome in the acute phase.

Three versus seven days to return-to-work after mild traumatic brain injury: a randomized parallel-group trial with neuropsychological assessment.

Although most patients with a mild traumatic brain injury (mTBI) recover within days to weeks, some experience persistent physical, cognitive and emotional symptoms, often described as post-concussion syndrome (PCS). The optimal recovery time including return-to-work (RTW) after mTBI is unclear. In this single-centre parallel-group trial, patients assigned three days (3D-group) or seven days (7D-group) sick leave were compared with a comprehensive neuropsychological test battery including the Post-Concussion Symptom Scale (PCSS) within one week, after three and 12 months post-injury. The influence of the effective time until RTW on post-concussional symptoms and cognitive performance was analysed. The 3D-group rated significantly higher mean scores in some PCSS symptoms, tended to fulfil diagnosis criteria of PCS more often and showed better cognitive performance in several neuropsychological test scores than the 7D-group at all three time-points of follow-up. Overall, patients returned to work 11.35 d post-injury, thus distinctly above both recommended sick leaves. There was a trend for longer sick leave in patients randomized into the 3D-group. Further analyses revealed that the group with an absolute RTW within one week showed lower symptom severity in fatigue at 3 and 12 months, less PCS and faster performance in fine motor speed at 12 months than the group with an absolute RTW after one week. Our data underline the heterogeneity of mTBI and show that acute and sub-acute symptoms are not prognostic factors for neuropsychological outcome at one year. Later, ability to work seems to be prognostic for long-term occurrence of PCS.

How to perform Point of Care Ultrasound at resuscitation and when it is useful.

Point of Care Ultrasound (POCUS) can be useful as a tool before, during and after the performance of cardiopulmonary resuscitation (CPR). Before or after resuscitation it can help with monitoring unstable hemodynamics, has the potential to identify reversible causes if patient deteriorates. During resuscitation POCUS can help detect potentially treatable causes of the cardiac arrest. Performance of POCUS while resuscitation requires experienced sonologists and a good team structure to embed the examination in advanced cardiovascular life support (ACLS) algorithms. This article gives an overview and tips about how to detect potential reversible causes of patient deterioration in all three phases of CPR. We describe some special situations in which resuscitation could take place. Further we give a comment about sonographic education of physicians and nonacademic medical staf.

[Initial assessment and management of acute poisonings]. / Beurteilung und Notfallmanagement bei akuten Vergiftungen.

In Switzerland about 250 severe or fatal cases of poisoning occur annually in adults, and approximately 25 cases of pediatric poisoning (calls to the Swiss Toxicological Information Centre). Patients with life-threatening symptoms need immediate intensive care according to their symptoms, regardless whether the responsible cause is known or not. In these cases the emergency ABCDE (Airway, Breathing, Circulation, Disabilities, Exposure) is used. The investigation of the cause of poisoning (identification of the responsible agents) and additional tests including ECG, lab analyses, and x-rays are performed at the same time. Their results are continuously included into the management of the poisoned patient. It is essential that the treatment chosen does not negatively interact with the known or potential toxicant thus worsening the symptoms. Specific treatments are possible only if the underlying toxicants are known, or if a toxidrome reveals a substance group as underlying cause of the condition, required for a targeted treatment.