Background
Current data on tranexamic acid (TXA) supports early administration for severe hemorrhagic shock. Administration by EMS has been facilitated by developing protocols and standing orders ...informed by these data. In this study, patterns of TXA use by EMS agencies serving a large level 1 trauma center were examined. We hypothesized that current widespread TXA use often includes administration outside of data-driven indications.
Methods
The trauma registry at a level 1 trauma center was queried for patients who received TXA. To determine the practice patterns and appropriateness of administration of TXA, patients’ physiologic state in the prehospital environment based on EMS records, physiologic state on arrival to hospital, and interventions performed in both settings were examined. Over 20 separately managed EMS systems that administer TXA transport patients to this trauma center, allowing for a broad survey of practices.
Results
From 2016 to 2021 1089 patients received TXA, 406 (37.3%) having treatment initiated by EMS services. Of these, the average prehospital systolic blood pressure (SBP) was 108.2 mmHg and initial ED SBP was 107.8 mmHg. Only 58.4% of these patients received blood transfusion after arrival to this trauma center. Compliance with standard indications was low with only 14.6% of administrations meeting any data-driven SBP indication. Similar levels of compliance were seen across high volume EMS services.
Discussion
Tranexamic acid use has become common in trauma and has been adopted by many EMS systems. These results indicate TXA in the prehospital setting is over-used as administration is not being limited to indications that have shown benefit in prior data.
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NUK, OILJ, SAZU, UKNU, UL, UM, UPUK
INTRODUCTIONTraumatic arterial injuries have a high degree of morbidity if left untreated. Frequently, arterial injuries are found soon after injury due to either subjective complaints or objective ...findings. Opportunity for delayed repair of vascular injury is a rare event as irreversible ischemia occurs at such early time points. CASE REPORTWe report a case of delayed presentation of complete arterial transection of the brachial artery due to penetrating trauma, but without classical hard signs of vascular injury. Trajectory, symptoms, and pulse exam prompted further evaluation. Successful reverse saphenous vein interposition grafting of the transected artery returned normal blood flow to the affected extremity with preserved function. CONCLUSIONThis case of delayed presentation of arterial transection is significant as delayed identification of arterial injury is rare. Furthermore, it demonstrates the need for clinicians to have a high index of suspicion in patients with traumatic limb injuries who present in a subacute or delayed fashion with increasing pain and worsening of initial physical exam findings.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Sports and energy drinks are being marketed to children and adolescents for a wide variety of inappropriate uses. Sports drinks and energy drinks are significantly different products, and the terms ...should not be used interchangeably. The primary objectives of this clinical report are to define the ingredients of sports and energy drinks, categorize the similarities and differences between the products, and discuss misuses and abuses. Secondary objectives are to encourage screening during annual physical examinations for sports and energy drink use, to understand the reasons why youth consumption is widespread, and to improve education aimed at decreasing or eliminating the inappropriate use of these beverages by children and adolescents. Rigorous review and analysis of the literature reveal that caffeine and other stimulant substances contained in energy drinks have no place in the diet of children and adolescents. Furthermore, frequent or excessive intake of caloric sports drinks can substantially increase the risk for overweight or obesity in children and adolescents. Discussion regarding the appropriate use of sports drinks in the youth athlete who participates regularly in endurance or high-intensity sports and vigorous physical activity is beyond the scope of this report.
BACKGROUND
Systemic hyperfibrinolysis is an integral part of trauma‐induced coagulopathy associated with uncontrolled bleeding. Recent data suggest that plasma‐first resuscitation attenuates ...hyperfibrinolysis; however, the availability, transport, storage, and administration of plasma in austere environments remain challenging and have limited its use. Freeze‐dried plasma (FDP) is a potential alternative due to ease of storage, longer shelf life, and efficient reconstitution. FDP potentially enhances clot formation and resists breakdown better than normal saline (NS) and albumin and similar to liquid plasma.
STUDY DESIGN AND METHODS
Healthy volunteers underwent citrated blood draw followed by 50% dilution with NS, albumin, pooled plasma (PP), or pooled freeze‐dried plasma (pFDP). Citrated native and tissue plasminogen activator (t‐PA)‐challenge (75 ng/mL) thrombelastography were done. Proteins in PP, pFDP, and albumin were analyzed by mass spectroscopy.
RESULTS
pFDP and PP had superior clot‐formation rates (angle) and clot strength (maximum amplitude) compared with NS and albumin in t‐PA‐challenge thrombelastographies (angle: pFDP, 67.9 degrees; PP, 67.8 degrees; NS, 40.6 degrees; albumin, 35.8 degrees; maximum amplitude: pFDP, 62.4 mm; PP, 63.5 mm; NS, 44.8 mm; albumin, 41.1 mm). NS and albumin dilution increased susceptibility to t‐PA‐induced hyperfibrinolysis compared with pFDP and PP (NS, 62.4%; albumin, 62.6%; PP, 8.5%; pFDP, 6.7%). pFDP was similar to PP in the attenuation of t‐PA‐induced fibrinolysis. Most proteins (97%) were conserved during the freeze‐dry process, with higher levels in 12% of pFDP proteins compared with PP.
CONCLUSION
pFDP enhances clot formation and attenuates hyperfibrinolysis better than NS and albumin and is a potential alternative to plasma resuscitation in the treatment of hemorrhagic shock.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
In pediatric hospitals, several factors interfere with the delivery of parenteral nutrition (PN). The purpose of this study was to assess the impact of a customized system of PN ordering on PN ...delivery, using a retrospective chart review before (n = 40) and after (n = 43) implementation of the system. No difference was observed in the proportions of children who did not receive the ordered amount of dextrose and amino acids (30% versus 23%, p = .49). Before customization, the subjects were more likely to receive intralipids (42% versus 19%, p = .02), and micronutrients (67% versus 9%, p < .0001) out of range. These results remained unchanged after adjustment for age, hospital unit, other fluids, and presence of a central line. Our findings highlight the discrepancy between ordered and received PN in pediatric patients. Customized PN ordering was associated with improved delivery of intralipids and micronutrients.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK, VSZLJ
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