Podcasts about prbcs

In this episode of EMS One-Stop, host Rob Lawrence dives into the trending topic of pre-hospital blood administration with guests from New Orleans EMS: Tom Dransfield, the quality assurance and safety officer, and Dr. David Rayburn, deputy medical director. This in-depth discussion explores the development and execution of the New Orleans EMS blood program, focusing on packed red blood cells (PRBC) and the challenges, successes and ongoing research surrounding cold blood administration in trauma and medical emergencies. New Orleans EMS is leading the charge in pushing the boundaries of pre-hospital blood, providing innovative solutions for penetrating trauma, GI bleeds and other critical cases. Dransfield and Dr. Rayburn share the journey of New Orleans EMS in implementing the program, including their logistics, lessons learned and the vital impact of their interventions on patient outcomes. The episode emphasizes the collaboration between EMS and trauma centers as well as blood suppliers to reduce mortality rates, while also tackling key questions, such as the supply chain, funding and future research. Memorable quotes "For every minute we delay blood administration, there's an 11% increase in mortality – this isn't just a theory; it's life and death." — Dr. David Rayburn "We were topping the charts in the wrong categories – violence and stuff like that. So, our medics were frustrated with the old scoop and run. We're not just scooping and running anymore. We're providing definitive care." — Tom Dransfield "We're seeing no change in temperature for patients receiving two units of cold PRBCs in the pre-hospital environment, and that's groundbreaking." — Dr. David Rayburn "If we're doing blood, we're literally saving lives. But without reimbursement, it's an uphill battle." — Rob Lawrence "Our paramedics are pushing the envelope – it's no longer just about trauma; we're now treating GI bleeds, OB cases and renal patients with blood administration." — Dr. David Rayburn Find more episodes: https://www.ems1.com/ems-one-stop

CME credits: 1.50 Valid until: 31-03-2024 Claim your CME credit at https://reachmd.com/programs/cme/andexanet-alfa-is-associated-with-lower-in-hospital-mortality-compared-to-4-factor-prothrombin-complex-concentrate-in-patients-with-factor-xa-inhibitorrelated-major-bleeding/14863/ Patients presenting to the hospital with severe bleeding and underlying treatment with Factor Xa (FXa) or Factor IIa inhibitors represent an enormous challenge to providers and clinicians since the approvals of apixaban, edoxaban, rivaroxaban, and dabigatran within the United States. Intracranial bleeding, intra-abdominal or thoracic trauma, gastrointestinal bleeding, and bleeding from any non-compressible source represent true life-threatening emergencies. Treatment of severe bleeding in patients receiving Factor Xa and Factor IIa inhibitors currently involves using non-specific therapy such as blood factor replacement - packed red blood cells (pRBCs), fresh frozen plasma, and platelets. With the development and approval of reversal agents, treatment of severe bleeding can now be specifically directed at the source of the coagulopathy combined with appropriate blood factor replacement. Nationally recognized guidelines have provided clear direction on how best to manage these types of major bleeding events. While published guidelines are an important resource in helping direct how to appropriately intervene, the inherent clinical and system challenge is as follows: How do I justify and juxtapose the clinical rationale for using a reversal agent with the inherent cost associated with it with a lack of comparative head-to-head studies? Our assessment of learners suggests that knowledge and …

CME credits: 1.50 Valid until: 31-03-2024 Claim your CME credit at https://reachmd.com/programs/cme/life-threatening-bleeding-in-the-anticoagulated-patient-real-world-evidence/14864/ Patients presenting to the hospital with severe bleeding and underlying treatment with Factor Xa (FXa) or Factor IIa inhibitors represent an enormous challenge to providers and clinicians since the approvals of apixaban, edoxaban, rivaroxaban, and dabigatran within the United States. Intracranial bleeding, intra-abdominal or thoracic trauma, gastrointestinal bleeding, and bleeding from any non-compressible source represent true life-threatening emergencies. Treatment of severe bleeding in patients receiving Factor Xa and Factor IIa inhibitors currently involves using non-specific therapy such as blood factor replacement - packed red blood cells (pRBCs), fresh frozen plasma, and platelets. With the development and approval of reversal agents, treatment of severe bleeding can now be specifically directed at the source of the coagulopathy combined with appropriate blood factor replacement. Nationally recognized guidelines have provided clear direction on how best to manage these types of major bleeding events. While published guidelines are an important resource in helping direct how to appropriately intervene, the inherent clinical and system challenge is as follows: How do I justify and juxtapose the clinical rationale for using a reversal agent with the inherent cost associated with it with a lack of comparative head-to-head studies? Our assessment of learners suggests that knowledge and …

CME credits: 1.50 Valid until: 31-03-2024 Claim your CME credit at https://reachmd.com/programs/cme/comparing-in-hospital-mortality-with-andexanet-alfa-versus-4-factor-prothrombin-complex-concentrate/14862/ Patients presenting to the hospital with severe bleeding and underlying treatment with Factor Xa (FXa) or Factor IIa inhibitors represent an enormous challenge to providers and clinicians since the approvals of apixaban, edoxaban, rivaroxaban, and dabigatran within the United States. Intracranial bleeding, intra-abdominal or thoracic trauma, gastrointestinal bleeding, and bleeding from any non-compressible source represent true life-threatening emergencies. Treatment of severe bleeding in patients receiving Factor Xa and Factor IIa inhibitors currently involves using non-specific therapy such as blood factor replacement - packed red blood cells (pRBCs), fresh frozen plasma, and platelets. With the development and approval of reversal agents, treatment of severe bleeding can now be specifically directed at the source of the coagulopathy combined with appropriate blood factor replacement. Nationally recognized guidelines have provided clear direction on how best to manage these types of major bleeding events. While published guidelines are an important resource in helping direct how to appropriately intervene, the inherent clinical and system challenge is as follows: How do I justify and juxtapose the clinical rationale for using a reversal agent with the inherent cost associated with it with a lack of comparative head-to-head studies? Our assessment of learners suggests that knowledge and …

Overview Hematocrit Normal Value Range Pathophysiology Special considerations Elevations in lab results Decreased HCT levels Nursing Points General Normal value range HCT measured in percentage Males – 41-50% Females – 36-44% Pathophysiology Measurement of total pRBCs compared to rest of blood volume Helps to indicate anemia Often measured with HGB (hemoglobin) Special considerations Lavender top tube (EDTA) Be cautious with technique Do not force sample into tube Can cause hemolysis Alters results Causes of HCT elevation Dehydration Change in % compared to total blood volume Respiratory disease COPD Pulmonary fibrosis Increased need for oxygen -> increased need for RBC production Polycythemia vera RBC overproduction due to bone marrow cancer Treatment includes bloodletting and increasing water consumption (also some medications) Causes of decreased HCT Blood loss Trauma Hemorrhage Treatment Stop bleeding Transfuse blood Anemia Kidney disease Decrease in EPO production Treatment Supplement with EPO Pregnancy Relative to increase total blood volume Leukemia Decreased bone marrow production causes ↓ RBC Treat leukemia via oncology pathways Chemotherapy Radiation Bone marrow transplant Assessment Assess for signs of anemia Tachycardia Fatigue Shortness of breath Decreased SaO2 Pallor Therapeutic Management Blood transfusions as necessary Treat primary cause of anemia Use oncologic methods to treat leukemia Bloodletting (phlebotomy) for polycythemia patients Nursing Concepts Lab Values Oxygenation

WB v. PRBCs in emergencies by TRANSFUSION's Monthly Podcast

CME credits: 1.50 Valid until: 31-03-2024 Claim your CME credit at https://reachmd.com/programs/cme/gi-bleeding-and-doacs-consensus-panel-findings/14866/ Patients presenting to the hospital with severe bleeding and underlying treatment with Factor Xa (FXa) or Factor IIa inhibitors represent an enormous challenge to providers and clinicians since the approvals of apixaban, edoxaban, rivaroxaban, and dabigatran within the United States. Intracranial bleeding, intra-abdominal or thoracic trauma, gastrointestinal bleeding, and bleeding from any non-compressible source represent true life-threatening emergencies. Treatment of severe bleeding in patients receiving Factor Xa and Factor IIa inhibitors currently involves using non-specific therapy such as blood factor replacement - packed red blood cells (pRBCs), fresh frozen plasma, and platelets. With the development and approval of reversal agents, treatment of severe bleeding can now be specifically directed at the source of the coagulopathy combined with appropriate blood factor replacement. Nationally recognized guidelines have provided clear direction on how best to manage these types of major bleeding events. While published guidelines are an important resource in helping direct how to appropriately intervene, the inherent clinical and system challenge is as follows: How do I justify and juxtapose the clinical rationale for using a reversal agent with the inherent cost associated with it with a lack of comparative head-to-head studies? Our assessment of learners suggests that knowledge and …

CME credits: 1.50 Valid until: 31-03-2024 Claim your CME credit at https://reachmd.com/programs/cme/annexa-i-recent-advances-in-the-treatment-of-intracranial-hemorrhage-ich/14865/ Patients presenting to the hospital with severe bleeding and underlying treatment with Factor Xa (FXa) or Factor IIa inhibitors represent an enormous challenge to providers and clinicians since the approvals of apixaban, edoxaban, rivaroxaban, and dabigatran within the United States. Intracranial bleeding, intra-abdominal or thoracic trauma, gastrointestinal bleeding, and bleeding from any non-compressible source represent true life-threatening emergencies. Treatment of severe bleeding in patients receiving Factor Xa and Factor IIa inhibitors currently involves using non-specific therapy such as blood factor replacement - packed red blood cells (pRBCs), fresh frozen plasma, and platelets. With the development and approval of reversal agents, treatment of severe bleeding can now be specifically directed at the source of the coagulopathy combined with appropriate blood factor replacement. Nationally recognized guidelines have provided clear direction on how best to manage these types of major bleeding events. While published guidelines are an important resource in helping direct how to appropriately intervene, the inherent clinical and system challenge is as follows: How do I justify and juxtapose the clinical rationale for using a reversal agent with the inherent cost associated with it with a lack of comparative head-to-head studies? Our assessment of learners suggests that knowledge and …

CME credits: 1.50 Valid until: 31-03-2024 Claim your CME credit at https://reachmd.com/programs/cme/summary-of-real-world-data-for-treatment-of-oral-factor-xa-related-major-bleeding/14867/ Patients presenting to the hospital with severe bleeding and underlying treatment with Factor Xa (FXa) or Factor IIa inhibitors represent an enormous challenge to providers and clinicians since the approvals of apixaban, edoxaban, rivaroxaban, and dabigatran within the United States. Intracranial bleeding, intra-abdominal or thoracic trauma, gastrointestinal bleeding, and bleeding from any non-compressible source represent true life-threatening emergencies. Treatment of severe bleeding in patients receiving Factor Xa and Factor IIa inhibitors currently involves using non-specific therapy such as blood factor replacement - packed red blood cells (pRBCs), fresh frozen plasma, and platelets. With the development and approval of reversal agents, treatment of severe bleeding can now be specifically directed at the source of the coagulopathy combined with appropriate blood factor replacement. Nationally recognized guidelines have provided clear direction on how best to manage these types of major bleeding events. While published guidelines are an important resource in helping direct how to appropriately intervene, the inherent clinical and system challenge is as follows: How do I justify and juxtapose the clinical rationale for using a reversal agent with the inherent cost associated with it with a lack of comparative head-to-head studies? Our assessment of learners suggests that knowledge and …

CME credits: 1.50 Valid until: 31-03-2024 Claim your CME credit at https://reachmd.com/programs/cme/clinical-implications-of-annexa-i-on-the-management-of-ich-for-neurointensivists-and-emergency-physicians/16131/ Patients presenting to the hospital with severe bleeding and underlying treatment with Factor Xa (FXa) or Factor IIa inhibitors represent an enormous challenge to providers and clinicians since the approvals of apixaban, edoxaban, rivaroxaban, and dabigatran within the United States. Intracranial bleeding, intra-abdominal or thoracic trauma, gastrointestinal bleeding, and bleeding from any non-compressible source represent true life-threatening emergencies. Treatment of severe bleeding in patients receiving Factor Xa and Factor IIa inhibitors currently involves using non-specific therapy such as blood factor replacement - packed red blood cells (pRBCs), fresh frozen plasma, and platelets. With the development and approval of reversal agents, treatment of severe bleeding can now be specifically directed at the source of the coagulopathy combined with appropriate blood factor replacement. Nationally recognized guidelines have provided clear direction on how best to manage these types of major bleeding events. While published guidelines are an important resource in helping direct how to appropriately intervene, the inherent clinical and system challenge is as follows: How do I justify and juxtapose the clinical rationale for using a reversal agent with the inherent cost associated with it with a lack of comparative head-to-head studies? Our assessment of learners suggests that knowledge and …

CME credits: 1.50 Valid until: 31-03-2024 Claim your CME credit at https://reachmd.com/programs/cme/emergency-medicine-perspectives-targeted-vs-nonspecific-approaches-to-anticoagulation-reversal-in-real-world-analyses-for-ich-or-gi-bleeds/14859/ Patients presenting to the hospital with severe bleeding and underlying treatment with Factor Xa (FXa) or Factor IIa inhibitors represent an enormous challenge to providers and clinicians since the approvals of apixaban, edoxaban, rivaroxaban, and dabigatran within the United States. Intracranial bleeding, intra-abdominal or thoracic trauma, gastrointestinal bleeding, and bleeding from any non-compressible source represent true life-threatening emergencies. Treatment of severe bleeding in patients receiving Factor Xa and Factor IIa inhibitors currently involves using non-specific therapy such as blood factor replacement - packed red blood cells (pRBCs), fresh frozen plasma, and platelets. With the development and approval of reversal agents, treatment of severe bleeding can now be specifically directed at the source of the coagulopathy combined with appropriate blood factor replacement. Nationally recognized guidelines have provided clear direction on how best to manage these types of major bleeding events. While published guidelines are an important resource in helping direct how to appropriately intervene, the inherent clinical and system challenge is as follows: How do I justify and juxtapose the clinical rationale for using a reversal agent with the inherent cost associated with it with a lack of comparative head-to-head studies? Our assessment of learners suggests that knowledge and …

CME credits: 1.50 Valid until: 31-03-2024 Claim your CME credit at https://reachmd.com/programs/cme/pharmacy-perspectives-real-world-management-of-factor-xa-inhibitor-associated-bleeding-across-45-us-hospitals/14860/ Patients presenting to the hospital with severe bleeding and underlying treatment with Factor Xa (FXa) or Factor IIa inhibitors represent an enormous challenge to providers and clinicians since the approvals of apixaban, edoxaban, rivaroxaban, and dabigatran within the United States. Intracranial bleeding, intra-abdominal or thoracic trauma, gastrointestinal bleeding, and bleeding from any non-compressible source represent true life-threatening emergencies. Treatment of severe bleeding in patients receiving Factor Xa and Factor IIa inhibitors currently involves using non-specific therapy such as blood factor replacement - packed red blood cells (pRBCs), fresh frozen plasma, and platelets. With the development and approval of reversal agents, treatment of severe bleeding can now be specifically directed at the source of the coagulopathy combined with appropriate blood factor replacement. Nationally recognized guidelines have provided clear direction on how best to manage these types of major bleeding events. While published guidelines are an important resource in helping direct how to appropriately intervene, the inherent clinical and system challenge is as follows: How do I justify and juxtapose the clinical rationale for using a reversal agent with the inherent cost associated with it with a lack of comparative head-to-head studies? Our assessment of learners suggests that knowledge and …

CME credits: 1.50 Valid until: 31-03-2024 Claim your CME credit at https://reachmd.com/programs/cme/hematoma-expansion-and-clinical-outcomes-comparison-in-ich-clinical-trial-results-versus-real-world-care/14861/ Patients presenting to the hospital with severe bleeding and underlying treatment with Factor Xa (FXa) or Factor IIa inhibitors represent an enormous challenge to providers and clinicians since the approvals of apixaban, edoxaban, rivaroxaban, and dabigatran within the United States. Intracranial bleeding, intra-abdominal or thoracic trauma, gastrointestinal bleeding, and bleeding from any non-compressible source represent true life-threatening emergencies. Treatment of severe bleeding in patients receiving Factor Xa and Factor IIa inhibitors currently involves using non-specific therapy such as blood factor replacement - packed red blood cells (pRBCs), fresh frozen plasma, and platelets. With the development and approval of reversal agents, treatment of severe bleeding can now be specifically directed at the source of the coagulopathy combined with appropriate blood factor replacement. Nationally recognized guidelines have provided clear direction on how best to manage these types of major bleeding events. While published guidelines are an important resource in helping direct how to appropriately intervene, the inherent clinical and system challenge is as follows: How do I justify and juxtapose the clinical rationale for using a reversal agent with the inherent cost associated with it with a lack of comparative head-to-head studies? Our assessment of learners suggests that knowledge and …

Breadth over depth

Background: Currently, trauma resuscitation focuses on immediate hemorrhage control, resuscitation with blood products (i.e. PRBCs, plasma) and early administration of tranexamic acid.  The evidence for the use of blood-based resuscitation in the pre-hospital system has been mixed (PAMPer and COMBAT trials). While early administration of blood products makes physiologic sense, proof of benefit is important ... Read more The post REBEL Cast Ep109: The RePHILL Trial appeared first on REBEL EM - Emergency Medicine Blog.

How much of D5W vs. isotonic saline contributes to intravascular volume? How do you distinguish between oncotic pressure and tonicity? What balanced solutions do you reach for? What is the data behind using colloids like albumin as an intravascular expander? How much do pRBCs stay in the plasma? Show notes, Transcript and References:  https://www.coreimpodcast.com/2022/04/27/fluids-colloids-5-pearls-segment/Get CME-MOC credit with ACP: https://www.acponline.org/cme-moc/cme/internal-medicine-podcasts/core-im Time stamps:02:14 Intro04:26 Pearl 111:08 Pearl 220:43 Pearl 331:06 Pearl 435:06 Pearl 5Tags: IM Core, CoreIM, fluids, hypertonic, volume, crystalloid, tonicity, blood, nephrology, hospital medicine

I sat down with Cam Elgie (PGY-1, NOSM) for a fantastic conversation that covers: - The immense shift in responsibility upon starting residency in the OR and ward (MS4: help out, R1: take ownership) - The importance of humanizing patients when providing care - Key advice for staying well during call shifts (DRINK WATER!) If you're going to listen to any episode, this is the one. High yield, high energy, and clearly listed responsibilities make this a must-listen for incoming R1s. Timestamps: 0:00 to 3:00 - Unique highlights of NOSM (small program, excellent nature, early responsibility) 3:00 to 5:15 - Learning how to be a doctor (being responsible for patient safety, taking ownership of patients) 5:15 to 6:15 - Ward management (Pain, Medications, Disposition, Followup) 6:15 to 8:00 - Daily responsibilities (Rounding, Prioritizing, Organizing Dispo/FU, Preventing Complications), Keep the service moving 8:00 to 8:30 - Preoperative optimization (ABx, pRBCs, NPO, Meds), Follow patients postop 8:30 to 9:30 - Clinic (Injections, Autonomy, Documentation) 9:30 to 10:30 - Pre-OR Checklists (NPO, Meds, ABx, ACO, Cardiac risk, pRBC), Growth from Assisting to Ownership 10:30 to 12:15 - OR Mentality (Planning, Equipment, Table, Positioning, Tourniquet, Meds, TXA, Ancef, Allergies, Incision, Approach), Specifics (Incision, Retraction, Layers), Postop (Splint, Followup, Recovery) 12:15 to 14:25 - Time Management (Juggling pages, consults, cases, imaging on OR days), Teeing things up (Prioritize, Call Ahead) 14:25 to 15:00 - Having the confidence to attempt procedures, reductions, injections (Safely!) 15:00 to 16:30 - The difference between a poor resident and a great resident, treating patients like humans 16:30 to 17:45 - OR Advice: Mindful watching (Position, Body, Needle, Bite Size), Volume & Repetition 17:45 to 20:00 - Overcoming setbacks: feeling amateurish, difficulty seeing planes, having to "know everything", being handed the knife 20:00 to 21:15 - Cam's Golden Rule for Staying Well On Call!

The PJ Med Director and the PJ Medical Programs Manager discuss Ten key changes to the new handbook. The handbook is being formatted and then out for print with the Journal of Special Operations Medicine. DO NOT INSTITUTE THESE UNTIL THE HANDBOOK IS RELEASED OR YOUR FLIGHT DOC DIRECTS YOU TO. Updated MARCH assessment to align w/ JTS TCCC guidelines Moved pelvic binder to circulation, specified how/how not to assess pelvis Combat/Hemorrhagic Shock and blood protocol TXA – 2gm (1 minute slow IV push)-also used for suspected TBI cold stored type 'O' whole blood>fresh low titer-'O' whole blood >PRBCs and plasma>plasma alone>PRBCs alone>non-titered type ‘O’ fresh whole blood>non-titered type specific fresh whole blood added 10mL of 10% calcium gluconate “bougie assisted cric” method Added vent troubleshooting and adjustment guide General fluid guidance Omitted Hextend LR is primary crystalloid for non-hemorrhagic shock casualties (may still carry 100CC for med recon) Removing 3% Saline (see TBI protocol update) TBI Replaced 3% Saline with 30mL of 23.4% hypertonic saline (learn the technique first) Versed for active seizures, Keppra for prophylactic (depressed skull fx/penetrating head wounds) Procedural Sedation Replaced procedural analgesia w/ procedural sedation and provided protocol No longer promoting ketamine/fentanyl/versed rotation Dilauded f/ long term pain control in hemodynamically stable Ketamine for unstable Medications added to formulary to support ATP small unit care capability/modified TMEPS Famotidine (Pepcid) – Zantac replacement Amoxicillin Azithromycin 1% Hydrocortisone cream Metronidazole (Flagyl) Malarone/primaquine Ciprofloxacin 4% saline Medications removed Albumin Ranitidine (Zantac) CBRNE updates Added CRESS acronym (Consciousness, Respirations, Eyes, Secretions, Skin)-NATO method Added MARCH Squared Updated Cyanide Antidote Hydroxycobalimin, Sodium thiosulfate and activated charcoal Doc Dorsch then gives us an ATP update amongst other intel. THAT OTHERS MAY LIVE  

If you didn't listen to the recent podcast put out by Tyler Christifulli and FOAMfrat called "Trigger Happy Transfusion Confusion" please download and listen via the FOAMfrat podcast feed. Tyler does a great job and provides out of the box thinking on the hot topic of PRBC administration in the transport environment. This "Response" podcast is based on my commentary, overall thoughts on the topic, additional topic points to consider and an overall review of the data related to PRBCs, FFP, and the recently published PAMPer trial. We couldn’t make this podcast without. Please rate, and review wherever you download the podcast. Thanks for listening!

If you didn't listen to the recent podcast put out by Tyler Christifulli and FOAMfrat called "Trigger Happy Transfusion Confusion" please download and listen via the FOAMfrat podcast feed. Tyler does a great job and provides out of the box thinking on the hot topic of PRBC administration in the transport environment. This "Response" podcast is based on my commentary, overall thoughts on the topic, additional topic points to consider and an overall review of the data related to PRBCs, FFP, and the recently published PAMPer trial. We couldn't make this podcast without. Please rate, and review wherever you download the podcast. Thanks for listening!See omnystudio.com/listener for privacy information.

This week we discuss upper GI bleeding pearls from a workshop we did in our weekly conference. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_72_0-UGIB_Final_Cut.m4a Download Leave a Comment Tags: Aortoenteric Fistula, Gastric Ulcer, Gastrointestinal, GI, UGIB, Variceal Bleeding Show Notes Take Home Points Respect the UGIB. These patients can bleed a lot. Even if they're not actively hemorrhagic in front of you, realize that they can open up at any time and decompensate Get your consultants on board early. A skilled endoscopist is your friend as they can get control of bleeding. Don't forget IR for TIPS in variceal bleeds and general surgery in bleeding ulcers. Activate your massive transfusion protocol if the patient is unstable and give the patient PRBCs, FFP and platelets as indicated. Reverse any anticoagulants as well. Give all patients with confirmed or suspected variceal bleeding antibiotics – typically, ceftriaxone. This intervention saves lives and decreases morbidity. Read More LITFL: EBM Upper GI Haemorrhage

This week we discuss upper GI bleeding pearls from a workshop we did in our weekly conference. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_72_0-UGIB_Final_Cut.m4a Download Leave a Comment Tags: Aortoenteric Fistula, Gastric Ulcer, Gastrointestinal, GI, UGIB, Variceal Bleeding Show Notes Take Home Points Respect the UGIB. These patients can bleed a lot. Even if they’re not actively hemorrhagic in front of you, realize that they can open up at any time and decompensate Get your consultants on board early. A skilled endoscopist is your friend as they can get control of bleeding. Don’t forget IR for TIPS in variceal bleeds and general surgery in bleeding ulcers. Activate your massive transfusion protocol if the patient is unstable and give the patient PRBCs, FFP and platelets as indicated. Reverse any anticoagulants as well. Give all patients with confirmed or suspected variceal bleeding antibiotics – typically, ceftriaxone. This intervention saves lives and decreases morbidity. Read More LITFL: EBM Upper GI Haemorrhage EMCrit:

A 5-year-old boy was playing with his older brother in front of their home when he was struck by a car. He sustained a femur fracture, splenic laceration, and blunt head trauma – the so-called Waddell’s triad. On arrival, he was in compensated shock, with tachycardia. He decompensates and needs blood. How do we manage his hemodynamics and when do we perform massive transfusion? Pediatric Massive Transfusion 40 mL/kg of blood products given at any time within the first 24 hours. Adolescents and Adult Massive Transfusion 6-8 units of packed red blood cells (PRBCs) Adults have about 5 L of circulating blood. Not including plasma, one could replace all circulating erythrocytes with about 10 units of PRBCS The best ratio of PRBCs:Plasma:Platelets is unknown, but consensus is 1:1:1. 1 unit of PRBCS is typically 300 mL of volume. The typical initial transfusion of PRBCs in children is 10 mL/kg. Massive transfusion in children is defined as 40 mL/kg of any blood product. Once you start to give a child with major trauma the second 10 mL/kg dose of PRBCs – start thinking about other blood components, and ask yourself whether you should initiate your massive transfusion protocol. The goal is to have the products ready to use in the case of the dynamic trauma patient. The Thromboelastogram (TEG) Direct measures the four components of clot formation. When there is endolethial damage and bleeding, the sequence that your body takes to address it is as follows:  Platelets migrate and form a plug Clotting factors aggregate and reinforce the platelets Fibrin arrives an acts like glue Other cells migrate and support the clot. R time – reaction time – the initial line in the tracing that shows time to beginning of clot formation. Treated with platelets K factor – kinetics of the clot –how much the clot allows the pin to move, or the amplitude. Treated with cryoprecipitate Alpha angle – the slope between the R and K measurements – reflects how quickly the fibrin glue is working. Treated with cryoprecipitate Ma – maximum amplitude – reflects the overall strength of the clot. Treated with platelets LY30 – the clot lysis at 30 min – is the decrease in strength of the clot’s amplitude at 30 min. Treated with an antifibrinolytics (tranexamic acid) Shape Recognition Red wine glass: a normal tracing with a normal reaction time and a normal amplitude. That patient just needs support and monitoring. Champagne glass: a coagulopathic TEG tracing – thinned out, with less amplitude. This patient needs specific blood products. Puffer fish or blob: a hyperfibrinolytic tracing. That patient will needs clot-stablizer. TEG – like the FAST – can be repeated as the clinical picture changes. The Trauma Death Spiral Lethal triad of hypothermia, acidosis, and coagulopathy. Keep the patient perfused and warm. Each unit of PRBCs contains 3 g citrate, which binds ionized calcium, causing hypotension. In massive transfusion, give 20 mg/kg of calcium chloride, up to 2 g, over 15 minutes. Calcium chloride is preferred, as it is ionically readily available – just use a larger-bore IV and watch for infiltration. Calcium gluconate could be used, but it requires metabolism into a bioavailable source of calcium. Prothrombin complex concentrate (PCC) Prothrombin complex concentrate (PCC) is derived from pooled human plasma and contains 25-30 times the concentration of clotting factors as FFP. Four-factor PCCs contain factors II, VII, IX and X, while 3-factor PCCs contain little or no factor VII. The typical dose of PCC is 20-50 units/kg In the severely hemorrhaging patient – you don’t have time to wait for the other blood products to thaw – PCC is a powder that is reconstituted instantly at the bedside. Tranexamic acid (TXA) Tranexamic acid (TXA), is an anti-fibrinolytic agent that functions by stopping the activation of plasminogen to plasmin, and the degradation of fibrin. The Clinical Randomisation of an Antifibrinolytic in Significant Hemorrhage (CRASH-2) investigators revealed a significant decrease in death secondary to bleeding when TXA was administered early following trauma. Based on the adult literature, one guideline is to give 15 mg/kg loading dose of TXA with a max 1 g over 10 minutes followed by 2 mg/kg/h for at least 8 h or until bleeding stops. Resuscitative Pearls Our goal here is damage control. Apply pressure whenever possible. Otherwise, resuscitate, identify the bleeding source, and slow or stop the bleeding with blood products or surgery. How Children are Different in Trauma In adults, we speak of “permissive hypotension” (also called “balanced resuscitation” or “damage control resuscitation”). The idea is that if we bring the adult patient’s blood pressure up to normal, we may be promoting clot rupture. To avoid this, we target a MAP of 65 and look for clinical signs of sufficient perfusion. Adults tolerate hypotension relatively well, and is sufficient until we send them to the OR or interventional radiology suite. In children, this is simply not the case. Hypotension in children is a sign of pre-arrest. Remember, they compensate with an increased systemic vascular resistance and tachycardia to maintain blood pressure. We should not allow children to become hypotensive – severe tachycardia alone should prompt us to resuscitate. In other words, permissive hypotension is not permissible for children. FAST is not sensitive enough to rule-out abdominal trauma. Fox et al in Academic Emergency Medicine found a sensitivity of 52%; with a 95% confidence interval [CI] = 31% to 73%. Often children even with high-grade splenic and liver lacerations can be managed non-operatively. If they are supported adequately, they are observed in the ICU and can avoid surgery in many cases. Unfortunately, a negative FAST cannot help with detecting or grading the laceration for non-operative management. In other words, feel free to use ultrasound – especially for things that we in the ED will react to and intervene on – but CT may help to manage the traumatized child non-operatively. General Guideline for Imaging in Pediatric Trauma CT Head and Neck, non-contrast: in concerning mechanisms of injury, patients that are difficult to assess (especially those under 3 months), those with a GCS of 13 or lower. CT Chest, IV contrast: for suspicion of vascular injury that needs exploration, especially in penetrating trauma. Otherwise, chest xray will tell you everything you need to know in children – especially in blunt trauma. Hemo or pneumothoraces are readily picked up by US or CXR. Rib fractures on CXR predict pulmonary contusions. If you are concerned about great vessel injury, then CT Chest may be helpful; otherwise consider omitting it. CT Abdomen and Pelvis, IV contrast: helpful in grading splenic and liver lacerations with goal to manage non-operatively. Abdominal tenderness to palpation, significant bruising, or a seat belt sign are concerning and would generally warrant a CT. Also, consider in liver function test abnormalities, or hematuria. Extremity injuries: in general can be evaluated with physical exam and plain films. However, some injuries in high-risk anatomically complex areas such as the hand and wrist, tibial plateau, and midfoot may be missed by plain films, and CT may be helpful here. Remember: you can help to mitigate post-traumatic stress and risk for adult healthcare aversion. Summary Massive transfusion in children is at 40 mL/kg of total blood products. Think about it if you are giving your second transfusion to the traumatized child. Do everything you can to support perfusion and avoid the death spiral of hypothermia, coagulopathy, and acidosis. Keep the child perfused with blood as needed, correct coagulopathy, avoid too much crystalloid, and make sure to use the least high-tech of all of these interventions – keep him dry and covered with warm blankets. Do a careful physical exam, and use CT selectively with an end-point in mind – the default is not the pan-scan – evaluate possible injuries depending on your suspicions from history, physical, and lab tests. Become familiar with the relatively new modalities in trauma such as TXA, cryoprecipitate and the emerging technology of thromboelestogram – red wine is good for you, champagne is weak, and a puffer fish is trouble. Selected References Dehmer JJ, Adamson WT. Massive transfusion and blood product use in the pediatric trauma patient. Semin Pediatr Surg. 2010 Nov;19(4):286-91. doi: 10.1053/j.sempedsurg.2010.07.002. Fox JC, Boysen M, Gharahbaghian L, Cusick S, Ahmed SS, Anderson CL, Lekawa M, Langdorf MI. Test characteristics of focused assessment of sonography for trauma for clinically significant abdominal free fluid in pediatric blunt abdominal trauma. Acad Emerg Med. 2011 May;18(5):477-82. Harvey V, Perrone J, Kim P. Does the use of tranexamic acid improve trauma mortality? Ann Emerg Med. 2014 Apr;63(4):460-2. Holscher CM, Faulk LW, Moore EE, Cothren Burlew C, Moore HB, Stewart CL, Pieracci FM, Barnett CC, Bensard DD. Chest computed tomography imaging for blunt pediatric trauma: not worth the radiation risk. J Surg Res. 2013 Sep;184(1):352-7. Nosanov L, Inaba K, Okoye O, Resnick S, Upperman J, Shulman I, Rhee P, Demetriades D. The impact of blood product ratios in massively transfused pediatric trauma patients. Am J Surg. 2013 Nov;206(5):655-60. Ryan ML, Van Haren RM, Thorson CM, Andrews DM, Perez EA, Neville HL, Sola JE, Proctor KG. Trauma induced hypercoagulablity in pediatric patients. J Pediatr Surg. 2014 Aug;49(8):1295-9. Scaife ER, Rollins MD, Barnhart DC, Downey EC, Black RE, Meyers RL, Stevens MH, Gordon S, Prince JS, Battaglia D, Fenton SJ, Plumb J, Metzger RR. The role of focused abdominal sonography for trauma (FAST) in pediatric trauma evaluation. J Pediatr Surg. 2013 Jun;48(6):1377-83. This post and podcast are dedicated to Larry Mellick, MS, MD, FAAP, FACEP. Thank you for your dedication to medical education, and sharing your warm bedside manner, extensive knowledge and talents, and your patient interactions with the world. Powered by #FOAMed — Tim Horeczko, MD, MSCR, FACEP, FAAP

Transfusion of packed red blood cells (pRBCs) is a common treatment for anemia. Transfusion to a normal PCV is unnecessary and may result in fluid overload due to the volume needed to return the PCV back to the normal range. The goal of pRBC transfusion is to alleviate the clinical signs associated with anemia or decreased oxygen content (CaO2). The question is: how much blood do you have to give to achieve the “desired packed cell volume (PCV)?” In this veterinary podcast, VetGirl will examine transfusion formulas to help you determine how much blood you need to give for these anemic patients.

Transfusion of packed red blood cells (pRBCs) is a common treatment for anemia. Transfusion to a normal PCV is unnecessary and may result in fluid overload due to the volume needed to return the PCV back to the normal range. The goal of pRBC transfusion is to alleviate the clinical signs associated with anemia or decreased oxygen content (CaO2). The question is: how much blood do you have to give to achieve the “desired packed cell volume (PCV)?” In this veterinary podcast, VetGirl will examine transfusion formulas to help you determine how much blood you need to give for these anemic patients.

For the second part of trauma resuscitation, we'll discuss the various interventions that you may have to accomplish in the trauma bay. The first part is a continuation from the first episode and talks about the EFAST exam- a vital part of the secondary survey. The second part discusses the control of massive extremity hemorrhage and how to intervene on any airway, breathing, or circulation issue in the trauma bay.

Blood products:   pRBCs, fresh frozen plasma, platelets, cryoprecipitate when and how should we use it?  What are the risks?  You may order them like IV fluids but do you really know how these potentially deadly products are to be used.