Penetrating junctional trauma is a leading cause of preventable death on the battlefield. Similarly challenging in civilian settings, exsanguination from the vessels of the abdomen, pelvis, and groin can occur in moments. Therefore, iliac artery or abdominal aortic compression has been recommended. Based on prior research, 120 lbs (54 kg) or 140 lbs (63 kg) of compression may be required to occlude these vessels, respectively. Whether most rescuers can generate this amount of compression is unknown.
To determine how many people in a convenience sample of 44 health care professionals can compress 120 lbs and 140 lbs.
This study simulated aortic and iliac artery compression. Consent was obtained from 44 clinicians (27 female; 17 male) from two large urban hospitals in Edmonton, Alberta, Canada. Participants compressed the abdominal model, which consisted of a medical scale and a 250 ml bag of saline, covered by a folded hospital blanket and placed on the ground. In random order, participants compressed a force they believed maintainable for 20 minutes ("maintainable effort") and then a maximum force they could maintain for two minutes ("maximum effort"). Compression was also performed with a knee. Descriptive statistics were used to evaluate the data.
Compression was directly proportional to the clinician's body weight. Participants compressed a mean of 55% of their body weight with two hands at a maintainable effort, and 69% at a maximum effort. At maintainable manual effort, participants compressed a mean of 86 lbs (39 kg). Sixteen percent could compress over 120 lbs, but none over 140 lbs. At maximum effort, participants compressed a mean of 108 lbs (48 kg). Thirty-four percent could compress greater than 120 lbs and 11% could compress greater than 140 lbs. Using a single knee, participants compressed a mean weight of 80% of their body weight with no difference between maintainable and maximum effort.
This work suggests that bimanual compression following penetrating junctional trauma is feasible. However, it is difficult, and is not likely achievable or sustainable by a majority of rescuers. Manual compression (used to temporize until device application and operative rescue) requires a large body mass. To maintain 140 lbs of compression (for example during a lengthy transport), participants needed to weigh 255 lbs (115 kg). Alternatively, they needed to weigh 203 lbs (92 kg) to be successful during brief periods. Knee compression may be preferable, especially for lower-weight rescuers.
Background Heparin dosage for anticoagulation during cardiopulmonary bypass (CPB) is commonly calculated based on the patient's body weight. The protamine-heparin ratio used for heparin reversal varies widely among institutions (0.7-1.3?mg protamine/100 IU heparin). Excess protamine may impair coagulation. With an empirically developed algorithm, the HeProCalc program, heparin, and protamine doses are calculated during the procedure. The primary aim was to investigate whether HeProCalc-based dosage of heparin could reduce protamine use compared with traditional dosages. The secondary aim was to investigate whether HeProCalc-based dosage of protamine affected postoperative bleeding. Patients and Methods We consecutively randomized 40 patients into two groups. In the control group, traditional heparin and protamine doses, based on body weight alone, were given. In the treatment group, the HeProCalc program was used, which calculated the initial heparin bolus dose from weight, height, and baseline activated clotting time and the protamine dose at termination of CPB. Results We analyzed the results from 37 patients, after exclusion of three patients. Equal doses of heparin were given in both groups, whereas significantly lower mean doses of protamine were given in the treatment group versus control group (211?±?56 vs. 330?±?61?mg, p?
External hemorrhage of extremities wounds is the leading cause of soldiers' death on the battlefield. In these cases control of massive arterial bleeding require not only prompt and effective measures, but also safety procedure. We assessed on volunteers the effectiveness, application time and pain intensity during the use of construction powerful quick-grip one-handed bar clamp. In results we found that the use of improvised quick-grip clamp for hemorrhage control in axillary and popliteal areas stops arterial blood flow in an extremity in all cases proven by Doppler ultrasound examination. Application time in axillary zone was 15.3 +/- 5.2 sec, in popliteal area--27.3 +/- 8.0 sec. In the groin area, the use of this improvised device was not effective due to technical characteristics (small distance between the main frame and the pressure surfaces). There do appear to be sufficient reasons to design the universal clamp for hemorrhage control from the wounds of junctional zones as well as proximal segments of extremities on Advanced Trauma Management stage and also for civilian prehospital emergency care.
BACKGROUND. To evaluate indications, efficacy, and complications associated with arterial embolization and prophylactic balloon catheterization in the management of obstetric hemorrhage at a university hospital. METHODS. Twenty-two women underwent arterial embolization between February 2001 and November 2003 for the treatment for primary postpartum hemorrhage resulting from abnormal placentation (n=11), uterine atony (n=7), paravaginal laceration (n=3), and disseminated intravascular coagulopathy (n=1). Blood loss was between 3.2 and 15 l. In seven patients, abnormal placentation was diagnosed prenatally and in these patients balloon catheterization was performed prophylactically before elective cesarean section. RESULTS. Of the seven patients, who underwent prophylactic catheterization, embolization was successful in five resulting in adequate hemostasis. Hysterectomy was performed in three, in two patients for uncontrolled hemorrhage and in one patient for placental invasion to bladder. There were no complications associated with prophylactic catheterization and embolization. The other 15 patients were treated in an emergency setting. In eight patients, embolization was performed as a primary surgery, and it was successful in six. In the other seven patients, hysterectomy was performed as an emergency surgery, but bleeding continued. Of these, in six patients, hemostasis was achieved with embolization. Complications associated with emergency embolization were observed in three patients. These were thrombosis of left popliteal artery, vaginal necrosis, and paresthesia of the right leg. CONCLUSIONS. Arterial embolization is of significant value in treating obstetric hemorrhage. Prophylactic insertion of balloon catheters before cesarean section seems to be a safe and effective method in controlling anticipated bleeding. In patients with persistent bleeding following cesarean section and hysterectomy, embolization could be a primary procedure before re-surgery.
This paper reports findings from a global survey of practice patterns for severe hemophilia A. Nurses from 105 hemophilia treatment centers in the US, the UK, Canada and Sweden responded to a questionnaire and provided data for more than 10,100 children and adults. Forty-eight percent of the US patients and 38 and 37% of the British and Swedish patients, respectively, were reported to have severe hemophilia A. The survey found that 28% of US patients and 38% of UK patients with severe hemophilia A were on primary prophylaxis in 2005. These rates were significantly higher than those reported in a 2003 survey. Sweden continues to lead the world in prophylaxis utilization, with virtually 100% of patients aged 3-18 on primary prophylactic regimens. Bleeding history and target joint development were major reasons for initiating prophylaxis; poor adherence, inadequate family commitment and venous access problems were cited as the top causes for discontinuing treatment. Nurses in all 4 reporting countries agreed that prophylaxis is the optimal therapy for patients with severe hemophilia A because it prevents joint and muscle damage and improves quality of life. They cited patient/family education as the most appropriate strategy for overcoming the barriers to prophylaxis.
Access to an adequate blood flow is a requirement for successful hemodialysis (HD). This often means repeated cannulation of an arteriovenous fistula (AVF), which can lead to damage that needs repair and revision. The Buttonhole (BH) method offers a successful cannulation with minimal damage.
A prospective cohort research study was initiated in two HD units in St. John's, Newfoundland and Labrador, to assess the effects of cannulating AVFs using the BH technique from the patient and nurse perspective.
Twenty-five nurses and 29 patients completed questionnaires at four times throughout the three-month study period, rating their confidence levels about BH cannulation issues. Patients also provided information on the pain of the cannulation and the frequency of cannulation complications. Nurses documented data on arterial and venous pressures, and hemostasis times. Patient charts were also reviewed for complications requiring extensive interventions such as AVF repair or Central Line Catheter (CVC) placement. The cost of providing the BH cannulation was also examined.
At the end of the study, it was noted that cannulation pain was statistically reduced with both the arterial (p = .002) and venous (p = .010) needles, and vessel pressures and hemostasis times were decreased slightly or stayed the same throughout the study. The frequency of access infections, however, increased, although not significantly. Using a 10-point Likert scale in which a score of > or = 8 indicates a high level of confidence, 77.5% of nurses and 73.9% of patients reported a high level of confidence in the nurses' abilities to use the BH technique effectively. In terms of expense, no significant changes were noted in frequency of procedures required for AVF repair with the BH cannulation, although an increase of approximately $358.80 per patient per year for BH supplies was noted.
BH cannulation did provide significant improvements. However, the increase in infection rate was an issue of concern. The additional cost of the BH procedure should be weighed against the positive outcomes realized.
The prophylactic treatment of bleeding in von Willebrand disease (vWD) has a long history in Sweden, having been first initiated in the late 1950s. The clinical experience of the prophylaxis of vWD in Sweden is described in the current review of a retrospective study of 37 patients from three haemophilia centres receiving prophylaxis for vWD. Prophylaxis with a plasma concentrate (fraction I-0 or Factor VIII) effectively reduced the median number of bleeds per year, prevented joint arthropathy in those who started prophylaxis at a young age, and improved the quality of life of all patients with vWD, particularly those with type 3 disease. This study demonstrates that the long-term prophylactic treatment with von Willebrand Factor (vWF)/FVIII concentrate (Haemate-P, ZLB Behring) in vWD is warranted in the majority of patients with type 3 disease.
A Nordic multicentre, open-label, non-interventional postmarketing surveillance study was carried out during a period of 24 months evaluating safety and efficacy of ReFacto as prophylactic or on-demand replacement therapy in patients with haemophilia A treated by self-medication. Fifty-seven patients were enrolled and studied for safety; efficacy was evaluated in 39 patients who received ReFacto for 24 months and recorded sufficient diary data on a hand-held computer. The compliance of using the device was good in small children, variable in adults and poor in teenagers. The fact that the overall compliance was low constituted a limitation of the number of patients with reliable diary data. Overall safety was rated as excellent or good by the clinicians for all patients at all visits and overall efficacy at 24 months evaluated to be excellent (74%) or good (26%). It was noticed that >/=50% of patients/parents reported no absences from school or work owing to bleeding episodes during the study period. Among patients on regular prophylaxis, 6 of the 30 patients (20%) receiving ReFacto experienced no bleeding episodes. A median of four bleeding episodes occurred during the 24-month study period, and 93% of the episodes were resolved with
Randomized trials suggest high-dose proton-pump inhibitors (PPIs) administered before gastroscopy in suspected upper gastrointestinal bleeding downstage bleeding ulcer stigmata. We assessed the cost-effectiveness of this approach.
A decision model compared high-dose IVPPI initiated while awaiting endoscopy with IVPPI administration on the basis of endoscopic findings. IVPPIs were given to all patients undergoing endoscopic hemostasis for 72 hours thereafter. Once the IV regimen was completed or for patients with low-risk endoscopic lesions, an oral daily PPI was given for the remainder of the time horizon (30 days after endoscopy). The unit of effectiveness was the proportion of patients without rebleeding, representing the denominator of the cost-effectiveness ratio (cost per no rebleeding). Probabilities and costs were derived from the literature and national databases.
IVPPIs before endoscopy were both slightly more costly and effective than after gastroscopy in the U.S. and Canadian settings, with cost-effectiveness ratios of US$5048 versus $4933 and CAN$6064 versus $6025 and incremental costs of US$45,673 and CAN$19,832 to prevent one additional rebleeding episode, respectively. Sensitivity analyses showed robust results in the US In Canada, intravenous proton-pump inhibitors (IVPPIs) before endoscopy became more effective and less costly (dominant strategy) when the uncomplicated stay for high-risk patients increased above 6 days or that of low-risk patients decreased below 3 days.
With conservative estimates and high-quality data, IVPPIs given before endoscopy are slightly more effective and costly than no administration. In Canada, this approach becomes dominant as the duration of hospitalization for high-risk ulcer patients increases or that of low-risk ulcer patients decreases.
CYP2C9 and VKORC1 gene polymorphism is inessential for bleeding development under conditions of oral application of anticoagulant acenocoumarol in Russian patients at high risk of thromboembolic complications.
The study included 52 patients at a high risk of thromboembolic complications, with permanent atrial fibrillation. All patients were treated with acenocoumarol for 6 months and the incidence of hemorrhages was evaluated in all of them. All patients were genotyped by CYP2C9 and VKORC1. The presence of CYP2C9*2 and CYP2C9*3 alleles of CYP2C9 locus and AA genotype of VCORC1 gene polymorphic G-1639(3673)A marker was not associated with the development of hemorrhages under conditions of acenocoumarol treatment (p=0.144 for CYP2C9, p=0.809 and 0.918 for VCORC1 in the total group and subgroup of patients with CYP2C9*1/*1 genotype, respectively). The search for other genetic markers of acenocoumarol efficiency and safety is needed for predicting the risk of hemorrhages during this treatment.