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20 results

  • The Pathophysiology of Injuries and Deaths Managed in Emergency Departments After Earthquake Disasters: A Narrative Review

  • Sarper Yilmaz, Ali Cankut Tatliparmak, Rohat Ak
  • Journal:
    Disaster Medicine and Public Health Preparedness / Volume 18 / 2024
    Published online by Cambridge University Press:
    04 November 2024, e252
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  • Earthquakes cause devastating effects, resulting in the deaths of thousands of people each year. Understanding the full range of impacts, including fatalities, and the pathophysiological mechanisms underlying these effects is crucial for mitigating the aftermath of earthquakes. Therefore, this review aims to: delineate the critical golden time periods following earthquakes and identify the most effective responses and resilience factors during these periods; accurately define the terminology for injuries sustained post-earthquake; elucidate the basic pathophysiology of CRUSH injury-induced myopathy, one of the most significant pathologies in post-earthquake patient management; explore the role of nitric oxide (NO) mechanisms in crush injuries, which are believed to be fundamental to the “smiling death phenomenon” and represent the unseen part of the iceberg; and highlight the importance of the 3 main phenomena responsible for mortality—acidosis, coagulopathy, and hypothermia—during disasters. This comprehensive review, based on the latest literature, encompasses search and rescue, pre-hospital processes, emergency department procedures, and subsequent internal and surgical management algorithms.

  • Epidemiology of severe bleeding in children following cardiac surgery involving cardiopulmonary bypass: use of Bleeding Assessment Scale for critically Ill Children (BASIC)

  • Lisa M. Bartucca, Ramzi Shaykh, Arabella Stock, Jeffrey D. Dayton, Emile Bacha, Kelly D. Haque, Marianne E. Nellis
  • Journal:
    Cardiology in the Young / Volume 33 / Issue 10 / October 2023
    Published online by Cambridge University Press:
    14 November 2022, pp. 1913-1919
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  • Objectives:

    To describe the epidemiology of severe bleeding in the immediate post-operative period in children who undergo cardiopulmonary bypass surgery using the Bleeding Assessment Scale for critically Ill Children (BASIC).

    Study design:

    Retrospective cohort study in a paediatric ICU from 2015 to 2020.

    Results:

    356 children were enrolled; 59% were male with median (IQR) age 2.1 (0.5–8) years. Fifty-seven patients (16%) had severe bleeding in the first 24 hours post-operatively. Severe bleeding was observed more frequently in younger and smaller children with longer bypass and cross-clamp times (p-values <0.001), in addition to higher surgical complexity (p = 0.048). Those with severe bleeding received significantly more red blood cells, platelets, plasma, and cryoprecipitate in the paediatric ICU following surgery (all p-values <0.001). No laboratory values obtained on paediatric ICU admission were able to predict severe post-operative bleeding. Those with severe bleeding had significantly less paediatric ICU-free days (p = 0.010) and mechanical ventilation-free days (p = 0.013) as compared to those without severe bleeding.

    Conclusions:

    Applying the BASIC definition to our cohort, severe bleeding occurred in 16% of children in the first day following cardiopulmonary bypass. Severe bleeding was associated with worse clinical outcomes. Standard laboratory assays do not predict bleeding warranting further study of available laboratory tests.

  • 4.4 - Monitoring Coagulation, Including Thromboelastography

  • from Section 4 - Therapeutic Interventions and Organ Support
  • Edited by Ned Gilbert-Kawai, The Royal Liverpool Hospital, Debashish Dutta, Princess Alexandra Hospital NHS Trust, Harlow, Carl Waldmann, Royal Berkshire Hospital, Reading
  • Book:
    Intensive Care Medicine
    Published online:
    27 July 2023
    Print publication:
    01 December 2021, pp 473-476

  • Summary

    Key Learning Points

    1. 1. Coagulopathy is common in the ICU and abnormal results should be interpreted in the context of the patient’s clinical condition.

    2. 2. Conventional coagulation tests monitor the intrinsic and extrinsic pathways of coagulation and are the mainstay of haemostatic monitoring.

    3. 3. Full blood count and conventional coagulation tests have a turnaround time that renders them unhelpful in acute bleeding scenarios.

    4. 4. Point-of-care viscoelastic tests, such as thromboelastography (TEG®) and rotational thromboelastrometry (ROTEM®), can provide a rapid overview of coagulation from clot formation to lysis, demonstrating both hypo- and pro-coagulant states.

    5. 5. Algorithms based upon viscoelastic tests in bleeding patients have demonstrated a reduction in blood transfusion requirements.

  • 3.10.6 - Haemostasis, Coagulopathies and the Bleeding Patient

  • from Section 3.10 - Haematological and Oncological Disorders
  • Edited by Ned Gilbert-Kawai, The Royal Liverpool Hospital, Debashish Dutta, Princess Alexandra Hospital NHS Trust, Harlow, Carl Waldmann, Royal Berkshire Hospital, Reading
  • Book:
    Intensive Care Medicine
    Published online:
    27 July 2023
    Print publication:
    01 December 2021, pp 353-360

  • Summary

    Key Learning Points

    1. 1. Coagulation is a tightly regulated process controlled by interactions between the vessel, platelets, clotting factor enzymes, co-factors and inhibitors, aimed at stopping bleeding from damaged vessels.

    2. 2. Coagulation involves initiation, activation and propagation of platelet activity to generate a thrombin burst which polymerises fibrinogen to fibrin, plugging the vessel wall.

    3. 3. Coagulopathy is common in critically ill patients and is associated with increased illness severity and mortality.

    4. 4. The underlying cause of coagulopathy must be diagnosed and treated, whilst avoiding the unnecessary correction of laboratory test results, unless there is clinical bleeding or a surgical procedure required.

    5. 5. Disseminated intravascular coagulopathy is most commonly triggered by sepsis, leading to the consumption of clotting factors and platelets, which, in turn, causes bleeding and microthrombotic events. Treatment must be focused upon the underlying condition.

  • 6.4 - Management of the Critical Care Patient Following Liver Transplant

  • from Section 6 - Perioperative Care
  • Edited by Ned Gilbert-Kawai, The Royal Liverpool Hospital, Debashish Dutta, Princess Alexandra Hospital NHS Trust, Harlow, Carl Waldmann, Royal Berkshire Hospital, Reading
  • Book:
    Intensive Care Medicine
    Published online:
    27 July 2023
    Print publication:
    01 December 2021, pp 635-637

  • Summary

    Key Learning Points

    1. 1. The demand for liver transplantation (LT) is expected to rise over time due to an increasing prevalence of end-stage liver disease (ESLD).

    2. 2. Perioperative management of LT patients, who are increasingly co-morbid, can be challenging.

    3. 3. Post-operative care in the ICU may minimise complications, particularly cardiovascular, renal and respiratory pathologies.

    4. 4. Management of post-operative coagulopathy and transfusion requires viscoelastic and other testing, beyond standard laboratory assays.

    5. 5. A low threshold of suspicion is required for detection of complications, especially of the hepatic vasculature.

  • Title: Haematological disorders revealing a raticide suicide attempt: A case report

  • N. Messedi, W. Abid, I. Krichen, I. Frikha, R. Ouali, N. Halouani, C. Kallel, J. Aloulou
  • Journal:
    European Psychiatry / Volume 64 / Issue S1 / April 2021
    Published online by Cambridge University Press:
    13 August 2021, p. S828
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  • Introduction

    Suicide attempts are common in individuals with schizophrenia. These actions are marked by a greater lethality, due to the use of more violent means in particular the intentional ingestion of rodenticides.

    Objectives

    To describe the gravity of the heamatological disorders revealing suicide attempts by a rodenticides in patient with schizophrénia.

    Methods

    We repport the case of a patient who present a haematological disorders after an rodenticide intoxication.

    Results

    A 41-year-old man with schizophrénia since 2011 was brought to the department of psychiatry in july 2020 for behavioral disorders. On arrival, the patient was oriented but reticent and refuse to tell his full story. On examination, his vital signs were normals, and he did not show any externalized bleeding. Bilogical tests revealed the prothrombin time (PT) was <10% with an isolated and unexplained fall in vitamin K-factors. The etiological investigation was negative. Later,the patient admitted attempted suicide by taken 4 rodenticide packages orally three days prior admission to hospital. The initial treatment with intravenous vitamin K almost daily is effective. An improvement in PT (35%) and vitamin K-dependent factors was observed after one week of treatment. A Normalization of hemostasis disorders was obtained after two weeks of treatment.

    Conclusions

    It is imperative to suspect rodenticide intoxication in patient with scizophrenia with an isolated and an explained deficiency of vitamin K dependent factors. The particularity of this intoxication lies in the dangerous and prolonged side effects making the curative treatment difficult and long.

    Disclosure

    No significant relationships.

  • Chapter 13 - Acute Treatment of Intracerebral Haemorrhage

  • from Part IV - Acute Treatment of Haemorrhagic Stroke
  • Edited by Jeffrey L. Saver, Graeme J. Hankey, University of Western Australia, Perth
  • Book:
    Stroke Prevention and Treatment
    Published online:
    15 December 2020
    Print publication:
    10 December 2020, pp 239-259

  • Summary

    Acute non-traumatic intracerebral haemorrhage (ICH) has a poor prognosis and is the least treatable form of acute stroke.Although less common than acute ischaemic stroke, ICH causes greater premature loss of productive life years on a global scale due to its predilection to affect people at younger ages with devastating consequences.Prognosis from ICH is related to location, initial volume and speed of expansion of the haematoma, and associated intraventricular haemorrhage. Care in a specialised stroke or neurointensive care unit improves outcome. Surgical haematoma evacuation should be pursued as for patients with cerebellar haemorrhage with neurologic deterioration, hydrocephalus, orsd brainstem compression. Haematoma evacuation may be considered, as a life-saving measure, in patients with coma or large haematoma with mass effect.Minimally-invasive surgery in stable patients is of uncertain benefit and is being evaluated in RCTs.Clinicians should not routinely use haemostatic therapies where there is no evidence of coagulopathy or anticoagulant use.When coagulopathy is present, early corrective measures should be taken. Early moderate intensity BP lowering to a systolic BP target of 140 mmHg is reasonable.Medical therapies to reduce mass effect and intracranial pressure should not be used routinely, but hyperventilation and hypertonic saline or colloidal osmotic agents are reasonable in patients with imminent herniation as a bridge to definitive neurosurgical intervention. Corticosteroids should be avoided.Novel neuroprotective approaches hold promise.

  • P001: Proof-of-principle in a large animal pilot: cardiac arrest may be associated with acute, transient coagulopathy that may drive post-cardiac arrest syndrome

  • C. Yeh, B. Camilotti, H. Hanif, R. Mohindra, C. Sun, P. Kim, S. Lin, M. Sholzberg
  • Journal:
    Canadian Journal of Emergency Medicine / Volume 22 / Issue S1 / May 2020
    Published online by Cambridge University Press:
    13 May 2020, pp. S64-S65
    Print publication:
    May 2020
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  • Introduction: Many cardiac arrest survivors die later due to hemorrhage or thromboembolism, thought to be caused by acquired coagulopathy in post-cardiac arrest syndrome (PCAS) from shock and reperfusion injury. Understanding PCAS is a priority identified by the AHA for the prevention of complications in cardiac arrest survivors. Shock dysregulates both coagulation and fibrinolysis. The key effector enzyme thrombin (Th), is responsible for both up- and down-regulating coagulation and fibrinolysis. Measuring early Th activity may allow for predicting PCAS coagulopathy, and early medical intervention in the ED. Therefore, we aimed to characterize the time-course profile of early coagulation using an established pig model of cardiac arrest. Methods: Yorkshire pigs were anaesthetised and intubated, had VF-arrest induced by pacing, and were resuscitated per ACLS. Rotational thromboelastometry (ROTEM) was performed on whole blood at four times: baseline, intra-arrest, post-arrest, and death, using the fibrin-based test with tissue factor to initiate clotting in the presence of a platelet inhibitor cytochalasin D (FIBTEM). Clot time (CT), clot formation time (CFT), alpha-angle during clot formation (Alpha), clot amplitude at 10 min (A10), maximum clot firmness (MCF), and maximum lysis as total percentage (ML%) were quantified. The primary outcome is the overall coagulation initiation measured by CFT, while secondary outcomes include ROTEM parameters reflecting Th activity. Parameters are compared over time in SPSS using repeated measures ANOVA and Bonferroni correction. Results: Pilot data from one experiment show that cardiac arrest causes immediate early changes to coagulation that subsequently normalized with ROSC (Figure 1). CFT was impaired immediately upon cardiac arrest (2.3-fold increase), normalized with ROSC, and impaired again at death when compared with baseline. Consistent with clotting impairment, A10, Alpha, and MCF were all reduced with cardiac arrest, normalized with ROSC, and impaired again at death. Conclusion: Higher initial indices of coagulopathy in patients with cardiac arrest appear to correlate with death and thromboembolism. In this pilot, CFT is acutely modified by cardiac arrest. Since CFT is affected by overall Th activity, early Th dysregulation may be a critical driver of coagulopathy. Th may therefore be a lead target that is modifiable in the emergency post-arrest setting to decrease morbidity and mortality from PCAS in cardiac arrest survivors.

  • The practicalities and barriers of using TEG6s in code red traumas: an observational study in one London major trauma centre

  • Sarah Morton, Judi Galea, James Uprichard, Anthony Hudson
  • Journal:
    Canadian Journal of Emergency Medicine / Volume 21 / Issue 3 / May 2019
    Published online by Cambridge University Press:
    20 September 2018, pp. 361-364
    Print publication:
    May 2019
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  • Objective

    Trauma induced coagulopathy is a disorder of the coagulation pathway that occurs following major trauma. “Code red trauma” require massive hemorrhage protocol activation. The aim was to qualitatively establish the reasons TEG is not currently utilized and the ongoing practicalities in performing a TEG sample for trauma-related massive hemorrhage.

    Methods

    A pilot study was performed using a TEG6s machine within one central London Major Trauma Centre’s resuscitation department. Staff were asked to run a TEG sample on any “code red” patient who attended during the trial. Staff were given questionnaires both before and after the trial to assess the knowledge around TEG.

    Results

    A TEG sample was performed in 75% of the sixteen “code red traumas,” with one sample being unsuccessful. Only one patient had their blood component management altered due to the TEG result with only 50% of consultants and registrars surveyed feeling confident in interpreting TEG results.

    Conclusion

    TEG6s samples can be run within the resuscitation department in a “code red trauma.” However, there is a significant lack of knowledge relating to TEG within the emergency department which is likely to hinder its impact on personalized blood component management. More research is required in how to provide appropriate education in a busy setting to enable TEG to be utilized appropriately.

  • 49 - Disseminated intravascular coagulation and thrombotic thrombocytopenic purpura/hemolytic uremic syndrome

  • from Section 8 - Hematology–oncology emergencies
  • Edited by Kaushal Shah, Jarone Lee, Kamal Medlej, American University of Beirut, Scott D. Weingart
  • Book:
    Practical Emergency Resuscitation and Critical Care
    Published online:
    05 November 2013
    Print publication:
    24 October 2013, pp 330-336

  • Summary

    This chapter discusses the diagnosis, evaluation and management of gastrointestinal bleeding including upper gastrointestinal bleeding (UGIB) and lower gastrointestinal bleeding (LGIB). It describes the special circumstances with regard to aortoenteric fistula, liver disease, and Jehovah's Witnesses. In UGIB, patients typically present with hematemesis, coffee-ground emesis, and/or melena. In LGIB, patients typically present with bright red blood per rectum (BRBPR), also known as hematochezia. Higher severity of disease is indicated by signs of shock such as hypotension, tachycardia, altered mental status (AMS), decreased urine output (UOP), cool skin, syncope, orthostasis. Change in pulse with posture is more sensitive than hypotension, but may be masked by medications (e.g., beta-blockers). Hypotension, tachycardia, and tachypnea can indicate hemorrhagic shock and requires immediate treatment. Massive transfusion protocols are helpful for significant bleeding in order to prevent further coagulopathy due to transfusion of high volume of crystalloid or only red cells.

  • Chapter 20 - Nutrition

  • from Section 3 - Special critical care tools and techniques
  • Edited by Marc van de Velde, Helen Scholefield, Lauren A. Plante
  • Book:
    Maternal Critical Care
    Published online:
    05 July 2013
    Print publication:
    04 July 2013, pp 203-216

  • Summary

    This chapter focuses on three entities namely disseminated intravascular coagulation (DIC), HELLP syndrome, and thrombotic thrombocytopenic purpura (TTP), which represents unique and critical threats to the well-being of mother and fetus during peripartum period. It is concerned with the etiology, clinical features, diagnostic methods and management of these entities. In non-bleeding patients with DIC, platelets and factor replacement should not be administered prophylactically or based on laboratory tests alone. The treatment of HELLP involves monitoring and responding to maternal signs and symptoms, particularly when pre-eclampsia is present, and includes fluid management and the use of antihypertensive agents and magnesium sulfate for seizure prophylaxis. Plasma exchange is the treatment of choice for TTP. The optimal treatment regimen for obstetric coagulation disorders continues to evolve, given the frequently dynamic clinical situation, the presence and health of the fetus, and a growing interest in conducting investigations during the peripartum period.

  • 17 - Acute puerperal uterine inversion

  • from Section 4 - PostpartumEmergencies
  • Edited by Edwin Chandraharan, Sabaratnam Arulkumaran
  • Book:
    Obstetric and Intrapartum Emergencies
    Published online:
    05 November 2012
    Print publication:
    11 October 2012, pp 120-125

  • Summary

    This chapter describes the types, key implications and management strategies of massive obstetric haemorrhage. Antepartum haemorrhage due to placental abruption and intrapartum haemorrhage due to uterine rupture are associated with increased perinatal mortality. Visible blood loss greater than 2 litres, ongoing bleeding are some key pointers of massive obstetric haemorrhage. Immediate management involves active resuscitation to ensure a patient airway, breathing and maintaining circulation with intravenous fluids, blood and blood products as well as correction of coagulopathy. In women who are not acutely compromised or bleeding severely, interventional radiology can be considered. If the bleeding is predominantly from the lower segment, a total abdominal hysterectomy is warranted. Women with massive obstetric haemorrhage often need multi-organ support. Hence, transfer to an intensive care unit or high dependency unit should be considered for monitoring. Thromboprophylaxis should be considered once the coagulation parameters return to normal.

  • Case 55 - Preoperativeevaluation

  • from Section I - Neuroanesthesia
  • Edited by George A. Mashour, Ehab Farag
  • Book:
    Case Studies in Neuroanesthesia and Neurocritical Care
    Published online:
    03 May 2011
    Print publication:
    03 February 2011, pp 177-181

  • Summary

    Anesthesia for complex spine surgery requires invasive monitoring, large-bore intravenous access, and awareness of the potential for disaster. Anesthesiologists involved in the care of patients undergoing complicated spine surgery should be cognitive of this infrequent but serious complication. This chapter presents a case study of a 75-year-old female who was scheduled for removal of instrumentation at L4-S1 and re-exploration of a previous posterior lumbar inter-body fusion. The intraoperative course was also complicated by significant coagulopathy from massive blood loss and transfusion. The postoperative course was complicated by nonoliguric renal failure, pneumonia, and urinary tract infection. The role of central venous monitoring is always debated in the context of major spine surgery. However, central venous pressure readings in the prone position may not reflect accurate data and large bore intravascular access and invasive blood pressure monitoring are probably more important in the hemodynamic management of these cases.

  • Case 83 - Sodiumabnormalities in neurocritical care

  • from Section II - Neurocritical care
  • Edited by George A. Mashour, Ehab Farag
  • Book:
    Case Studies in Neuroanesthesia and Neurocritical Care
    Published online:
    03 May 2011
    Print publication:
    03 February 2011, pp 277-280

  • Summary

    Acute liver failure (ALF) is a rare clinical syndrome characterized by coagulopathy and hepatic encephalopathy. Multisystem organ failure secondary to sepsis and cerebral herniation secondary to increased intracranial pressure (ICP) are the leading causes of death. The decision to place an ICP monitor to facilitate goal-directed management of intracranial hypertension remains controversial. Drug-induced hepatotoxicity remains the leading cause of ALF in the USA with acetaminophen overdose constituting approximately 50% of all cases. The prognosis for spontaneous recovery of liver function decreases with increasing severity of encephalopathy. The coagulopathy of ALF is multifactorial, including impaired synthesis of clotting factors and fibrinogen, increased peripheral consumption, and thrombocytopenia. While placement of an ICP monitor to facilitate goal-directed management of intracranial hypertension may insure that cerebral perfusion is preserved, the risks of intracranial hemorrhage from ICP monitor placement and blood product administration must be considered.

  • Feasibility of Use of ROTEM to Manage the Coagulopathy of Military Trauma in a Deployed Setting

  • Catherine Doran
  • Journal:
    Prehospital and Disaster Medicine / Volume 25 / Issue S2 / October 2010
    Published online by Cambridge University Press:
    17 February 2017, p. s96
    Print publication:
    October 2010
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  • Consumptive coagulopathy complicating juvenile angiofibroma

  • Campbell Baguley, Guri Sandhu, James O’Donnell, David Howard
  • Journal:
    The Journal of Laryngology & Otology / Volume 118 / Issue 11 / November 2004
    Published online by Cambridge University Press:
    08 March 2006, pp. 835-839
    Print publication:
    November 2004

  • Objective: To investigate the incidence and clinical significance of deranged clotting results among patients with juvenile (nasopharyngeal) angiofibroma.

    Methods: Twenty consecutive patients treated for juvenile angiofibroma between March 1998 and July 2002 in whom preoperative coagulation tests were performed were selected. Results were compared with normal laboratory values, and clinical and histological records were retrospectively analysed.

    Results: Four out of 20 patients were found to have abnormal tests, consistent with concurrent consumptive coagulopathies. One patient was found to have a raised D-dimer level. This resolved following removal of the lesion.

    Conclusions:The association between larger arterio-venous malformations and disseminated intravascular coagulopathy is well described (Kasabach–Merritt syndrome). Our findings suggest that low-grade consumptive coagulopathies may also complicate smaller juvenile angiofibromas, implying that preoperative coagulation screening tests may have a role in ensuring optimal perioperative haemostasis.