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Background: Massive hemorrhage protocols (MHPs) streamline the complex logistics required for prompt care of the bleeding patient, but their uptake has been variable and few regions have a system to measure outcomes from these events. Aim Statement: We aim to implement a standardized MHP with uniform quality improvement (QI) metrics to increase uptake of evidence-based MHPs across 150-hospitals in Ontario between 2017 and 2021. Measures & Design: We performed ongoing PDSA cycles; 1) stakeholder analysis by surveying the Ontario Regional Blood Coordinating Network (ORBCoN), 2) problem characterization and Ishikawa analysis for key QI metrics based on areas of MHP variability in 150 Ontario hospitals using a web-based survey, 3) creation of a consensus MHP via a modified Delphi process, 4) problem characterization at ORBCoN for the design of a freely available toolkit for provincial implementation by expert working groups, 5) design of 8 key QI metrics by a modified Delphi process, and 6) identification of process measures for QI data collection by implementation metrics. Evaluation/Results: PDSA1-2; 150-hospitals were surveyed. 33% of hospitals lacked MHPs, mostly in smaller sites. Major areas for QI were related to activation criteria, hemostatic agents, protocolized hypothermia management, variable MHP naming, QI metrics and serial blood work requirements. PDSA3; 3 Delphi rounds were held to reach 100% expert consensus for 42 statements and 8 CQI metrics. Major areas for modification were protocol name, laboratory resuscitation targets, cooler configurations, and role of factor VIIa. PDSA4; adaptable toolkit is under development by the steering committee and expert working groups. Implementation is scheduled for Spring 2020. PDSA5; the 8 CQI metrics are: TXA administration < 1 h, RBC transfusion < 15 min, call to transfer for definitive care < 60 min, temp >35°C at end of protocol, Hgb kept between 60-110g/L, transition to group-specific RBC by 90 min, appropriate activation defined by ≥6 units RBC in the first 24 hours, and any blood component wastage. Discussion/Impact: MHP uptake, content, and tracking is variable. A standardized MHP that is adaptable to diverse settings decreases complexity, improves use of evidence-based practices, and provides a platform for continuous QI. PDSA6 will occur after implementation; we will complete an implementation survey, and design a pilot and feasibility study for prospective tracking of patient outcomes using existing prospectively collected inter-hospital and provincial databases.
The optimal timing of anticoagulation after ischemic stroke in atrial fibrillation (AF) patients is unknown. Our aim was to demonstrate the feasibility and safety of initiating dabigatran therapy within 14 days of transient ischemic attack (TIA) or minor stroke in AF patients.
Patients and Methods:
A prospective, multi-center registry (NCT02415855) in patients with AF treated with dabigatran within 14 days of acute ischemic stroke/TIA (National Institutes of Health Stroke Scale (NIHSS) ≤ 3) onset. Baseline and follow-up computed tomography (CT) scans were assessed for hemorrhagic transformation (HT) and graded by using European Cooperative Acute Stroke Study criteria.
One hundred and one patients, with a mean age of 72.4 ± 11.5 years, were enrolled. Median infarct volume was 0 ml. Median time from index event onset to dabigatran initiation was 2 days, and median baseline NIHSS was 1. Pre-treatment HT was present in seven patients. No patients developed symptomatic HT. On the day 7 CT scan, HT was present in six patients (one progressing from baseline hemorrhagic infarction type 1). Infarct volume was a predictor of incident HT (odds ratio = 1.063 [1.020–1.107], p < 0.003). All six (100%) patients with new/progressive HT were functionally independent (modified Rankin Scale (mRS) = 0–2) at 30 days, which was similar to those without HT (90%, p = 0.422). Recurrent ischemic events occurred within 30 days in four patients, two of which were associated with severe disability and death (mRS 5 and 6, respectively).
Early dabigatran treatment did not precipitate symptomatic HT after minor stroke. Asymptomatic HT was associated with larger baseline infarct volumes. Early recurrent ischemic events may be clinically more important.
Post-surgical bleeding after tonsillectomy occurs in 2–7 per cent of cases. This study examined whether heart rate and haematocrit changes are associated with the amount of bleeding.
In this retrospective analytical study, data were collected from the medical charts of patients admitted with post-surgical bleeding.
Over the course of 10 years, there were 218 cases of post-operative bleeding in children aged under 18 years. There was a significant increase in heart rate after the bleeding had started, and a significant decrease in both haemoglobin and haematocrit levels (p < 0.05). There was no significant correlation between the differences in haemoglobin and haematocrit and changes in heart rate.
No correlation was found between the differences in haemoglobin and haematocrit levels and the changes in heart rate from before the surgery to after the bleeding had started. The monitoring of paediatric patients’ heart rate after tonsillectomy surgery solely for the purpose of predicting acute blood loss is therefore discouraged.
Tourniquets (TQs) save lives. Although military-approved TQs appear more effective than improvised TQs in controlling exsanguinating extremity hemorrhage, their bulk may preclude every day carry (EDC) by civilian lay-providers, limiting availability during emergencies.
The purpose of the current study was to compare the efficacy of three novel commercial TQ designs to a military-approved TQ.
Nine Emergency Medicine residents evaluated four different TQ designs: Gen 7 Combat Application Tourniquet (CAT7; control), Stretch Wrap and Tuck Tourniquet (SWAT-T), Gen 2 Rapid Application Tourniquet System (RATS), and Tourni-Key (TK). Popliteal artery flow cessation was determined using a ZONARE ZS3 ultrasound. Steady state maximal generated force was measured for 30 seconds with a thin-film force sensor.
Success rates for distal arterial flow cessation were 89% CAT7; 67% SWAT-T; 89% RATS; and 78% TK (H 0.89; P = .83). Mean (SD) application times were 10.4 (SD = 1.7) seconds CAT7; 23.1 (SD = 9.0) seconds SWAT-T; 11.1 (SD = 3.8) seconds RATS; and 20.0 (SD = 7.1) seconds TK (F 9.71; P <.001). Steady state maximal forces were 29.9 (SD = 1.2) N CAT7; 23.4 (SD = 0.8) N SWAT-T; 33.0 (SD = 1.3) N RATS; and 41.9 (SD = 1.3) N TK.
All novel TQ systems were non-inferior to the military-approved CAT7. Mean application times were less than 30 seconds for all four designs. The size of these novel TQs may make them more conducive to lay-provider EDC, thereby increasing community resiliency and improving the response to high-threat events.
Stop the Bleed (STB) is a national initiative that provides lifesaving hemorrhagic control education. In 2019, pharmacists were added as health-care personnel eligible to become STB instructors. This study was conducted to evaluate the efficacy of pharmacist-led STB trainings for school employees in South Texas.
Pharmacist-led STB trainings were provided to teachers and staff in Laredo, Texas. The 60-min trainings included a presentation followed by hands-on practice of tourniquet application, wound-packing, and direct pressure application. Training efficacy was assessed through anonymous pre- and postevent surveys, which evaluated changes in knowledge, comfort level, and willingness to assist in hemorrhage control interventions. Student volunteers (predominantly pharmacy and medical students) assisted in leading the hands-on portion, providing a unique interprofessional learning opportunity.
Participants with previous training (N = 98) were excluded, resulting in a final cohort of 437 (response rate 87.4%). Compared with baseline, comfort level using tourniquets (mean, 3.17/5 vs 4.20/5; P < 0.0001), opinion regarding tourniquet safety (2.59/3 vs 2.94/3; P < 0.0001), and knowledge regarding tourniquets (70.86/100 vs 75.84/100; P < 0.0001) and proper tourniquet placement (2.40/4 vs 3.15/4; P < 0.0001) significantly improved.
Pharmacist-led STB trainings are efficacious in increasing school worker knowledge and willingness to respond in an emergency hemorrhagic situation.
Interhemispheric subdural hematomas (IHSDHs) are thought to be rare. Surgical management of these lesions presents a challenge as they are in close proximity to the sagittal sinus and bridging veins. IHSDHs are poorly characterized clinically and their exact incidence is unknown. There are also no clear guidelines for the management of IHSDH.
This is a retrospective review of all admitted patients with a diagnosis of traumatic brain injury over a 4-year period at a Level I trauma centre. Clinical characteristics of all patients with subdural hematoma (SDH) and IHSDH were collected.
Of 2165 admissions, 1182 patients had acute traumatic SDHs, 420 patients had IHSDHs (1.9% of admissions and 35.5% of SDH), 35 (8.3% of IHSDH) were ≥8 mm in width. IHSDH was isolated in 16 (3.8%) of the cases. Average age was 61.7 ± 21.5 years for all IHSDHs and 77.1 ± 10.4 for large IHSDH (p < 0.001). For large IHSDH, a transient loss of consciousness (LOC) occurred in 51.5% of individuals, post-traumatic amnesia (PTA) in 47.8% of cases, and motor weakness in 37.9% of patients. Five of the large IHSDH patients presented with motor deficits directly related to the IHSDH, and weakness resolved in four of these five individuals. None were treated surgically. Progression of IHSDH width occurred in one patient.
IHSDHs are often referred to as rare entities. Our results show they are common. Conservative management is appropriate to manage most IHSDHs, as most resolve spontaneously, and their symptoms resolve as well.
Cold dissection is the most commonly used tonsillectomy technique, with low post-operative haemorrhage rates. Coblation is an alternative technique that may cause less pain, but could have higher post-operative haemorrhage rates.
This study evaluated the peri-operative outcomes in paediatric tonsillectomy patients by comparing coblation and cold dissection techniques.
A systematic review was conducted of all comparative studies of paediatric coblation and cold dissection tonsillectomy, up to December 2018. Any studies with adults were excluded. Outcomes such as pain, operative time, and intra-operative, primary and secondary haemorrhages were recorded.
Seven studies contributed to the summative outcome. Coblation tonsillectomy appeared to result in less pain, less intra-operative blood loss (p < 0.01) and a shorter operative time (p < 0.01). There was no significant difference between the two groups for post-operative haemorrhage (p > 0.05).
The coblation tonsillectomy technique may offer better peri-operative outcomes when compared to cold dissection, and should therefore be offered in paediatric cases, before cold dissection tonsillectomy.
External aortic compression (EAC) has long been used to control exsanguinating post-partum hemorrhage, but it has only recently been described in the prehospital trauma setting. This paper reports four cases where manual EAC was used during transport to manage life-threatening bleeding, twice from stab wounds, once from ruptured ectopic pregnancy, and once from severe lower-limb trauma. It showed that EAC has life-saving potential in the prehospital setting, but that safety and efficacy during transport requires the use of a hands-free compression device, such as an aortic tourniquet.
Low-resource environments, such as those found in humanitarian crises, pose significant challenges to the provision of proper medical treatment. While the lack of training of health providers to such settings has been well-acknowledged in literature, there has yet to be any scientific evidence for this phenomenon.
This pilot study utilized a randomized crossover experimental design to examine the effects of high- versus low-resource simulated scenarios of a resuscitation of a critically ill obstetric patient on a medical doctors’ performance and inter-personal skills. Ten senior residents (fifth-year post-graduate) of the Maggiore Hospital School of Medicine (Novara, NO, Italy) were included in the study.
Overall performance score for the high-resource setting was 5.2, as opposed to only 2.3 for the low-resource setting. The mean effect size for the overall score was 2.9 (95% CI, 1.7–4.0; P <.001). The results suggest a significant decrease in both technical (medical) and non-technical skills, such as leadership, problem solving, situation awareness, resource utilization, and communication in the low-resource environment setting. The latter finding is of special important since it was yet to be reported.
This pilot study suggests that untrained physicians in low-resource environments may experience a considerable setback not only to their professional performance, but also to their interpersonal skills, when deployed ill-prepared to humanitarian missions. Consequently, this may endanger the health of local populations.
In this chapter, the authors discuss numerous anesthetic considerations related to the care for the premature infant. A host of topics associated with prematurity are reviewed including bronchopulmonary dysplasia, pulmonary hypertension, apnea of prematurity, retinopathy of prematurity, cerebral palsy, neonatal hypoglycemia, hypothermia and acidosis, necrotizing enterocolitis and the performance of neonatal spinal anesthetics.
Patients with mechanical heart valves are at high thrombotic risk and require warfarin. Among those developing intracranial hemorrhage, limited data are available to guide clinicians with antithrombotic reinitiation. This 13-patient case series of warfarin-associated intracranial hemorrhages found the time to reinitiate antithrombotic therapy (17 days, interquartile range 21.5 days), and changes to international normalized ratio targets were variable and neither correlated with the type, location, or etiology of bleed, nor the valve and associated thromboembolic risk. The initial presentation significantly impacted prognosis, and diligent assessment and follow-up may support positive long-term outcomes.
Mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes (MELAS) is a rare progressive maternally inherited mitochondrial disease that clinically harbours various neurological and systemic manifestations.
To assess the effect of tranexamic acid on intra-operative bleeding and surgical field visualisation.
Fifty patients undergoing various endoscopic ear surgical procedures, including endoscopic tympanoplasty, endoscopic atticotomy or mastoidectomy, endoscopic ossiculoplasty, and endoscopic stapedotomy, were randomly assigned to: a study group that received tranexamic acid or a control group which received normal saline. The intra-operative bleeding and operative field visualisation was graded using the Das and Mitra endoscopic ear surgery bleeding and field visibility score, which was separately analysed for the external auditory canal and the middle ear.
The Das and Mitra score was better (p < 0.05) in the group that received tranexamic acid as a haemostat when working in the external auditory canal; with respect to the middle ear, no statistically significant difference was found between the two agents. Mean values for mean arterial pressure, heart rate and surgical time were comparable in both groups, with no statistically significant differences.
Tranexamic acid appears to be an effective haemostat in endoscopic ear surgery, thus improving surgical field visualisation, especially during manipulation of the external auditory canal soft tissues.
A single-centre, single-blinded prospective experimental study was conducted to determine the effectiveness of autologous platelet-rich plasma applied to the tonsillar bed post-operatively in reducing post-operative pain and haemorrhage.
Platelet-rich plasma, prepared prior to surgery, was applied with calcium gluconate to one randomly chosen tonsillar fossa. Pain and haemorrhage were analysed, using a visual analogue scale and a pre-defined grading scale respectively, four times on the day of surgery at 2-hourly intervals, and thrice on the following day.
The pain score and haemorrhage grade on the test side were lower than on the control side. These findings were statistically significant.
This pilot study, conducted in India, revealed valid positive results for a promising new technology. The manual preparation of platelet-rich plasma could be automated in the future to allow a larger sample size.
Ocular complaints prompt a significant number of emergency department (ED) visits, and they can range from benign to sight-threatening. Detailed fundoscopic examination is difficult, even for experienced providers. Point-of-care ultrasound (POCUS) is increasingly utilized in the ED for numerous applications, including ocular evaluation. We present a case in which ocular POCUS was used to diagnose a submacular hemorrhage in a patient who presented with acute painless loss of vision. Ocular POCUS can be readily employed to assess for myriad clinically significant pathologies.
Introduction: Controversy exists in antiepileptic drug (AED) prophylaxis prescribing in patients with aneurysmal subarachnoid hemorrhage (SAH). We undertook the Use of Antiepileptic Drugs in Aneurysmal Subarachnoid Hemorrhage (ALIBI) study to identify factors associated with prescribing practices. Methods: A retrospective chart review of all consecutive patients requiring Level 1 care with aneurysmal SAH admitted between 2012 and 2014 to the intensive care unit at Toronto Western Hospital, Ontario, Canada, was conducted. Data were collected on clinical and imaging characteristics. Primary and secondary outcomes were AED prophylaxis and clinical seizure activity during hospitalization. Data were compared using chi-square or Mann–Whitney U-tests. Those variables found to be significant, or trending toward significance, on univariate analysis were fitted to multivariate regression. Results: Sixty-eight patients were included. Mean age was 62 ± 12.2, and 42.6% of patients were male. Of these, 21 patients (30.9%) received AED prophylactically, while 18 (26.5%) had reported seizures at some point during hospitalization. Female gender and presence of midline shift (MLS) were significantly associated or approached significance with AED prophylaxis in univariate analysis (p = 0.036 and p = 0.062, respectively). In multivariate analysis, only MLS was an independent predictor (odds ratio 5.09, p = 0.04). Conclusion: The presence of MLS was an independent predictor of seizure activity in patients with aneurysmal SAH. AED prophylaxis prescribing patterns seemed arbitrary and was not informed by identifiable clinical factors or true risk factors for seizure. A current lack of evidence guiding AED prescribing practice highlights the need for larger studies in this patient population.
Epistaxis is the most common ENT emergency. This study aimed to assess one-year mortality rates in patients admitted to a large teaching hospital.
This study was a retrospective case note analysis of all patients admitted to the Queen Elizabeth University Hospital in Glasgow with epistaxis over a 12-month period.
The one-year overall mortality for a patient admitted with epistaxis was 9.8 per cent. The patients who died were older (mean age 77.2 vs 68.8 years; p = 0.002), had a higher Cumulative Illness Rating Scale-Geriatric score (9.9 vs 6.7; p < 0.001) and had a higher performance status score (2 or higher vs less than 2; p < 0.001). Other risk factors were a low admission haemoglobin level (less than 128 g/dl vs 128 g/dl or higher; p = 0.025), abnormal coagulation (p = 0.004), low albumin (less than 36 g/l vs more than 36 g/l; p < 0.001) and longer length of stay (p = 0.046).
There are a number of risk factors associated with increased mortality after admission with epistaxis. This information could help with risk stratification of patients at admission and enable the appropriate patient support to be arranged.