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Nonselective versus Selective Angioembolization for Trauma Patients with Pelvic Injuries Accompanied by Hemorrhage: A Meta-Analysis
Jang, H., Jeong, S. T., Park, Y. C., Kang, W. S.
Medicina (Kaunas, Lithuania). 2023;59(8)
Abstract
Background and Objectives: Angioembolization has emerged as an effective therapeutic approach for pelvic hemorrhages; however, its exact effect size concerning the level of embolized artery remains uncertain. Therefore, we conducted this systematic review and meta-analysis to investigate the effect size of embolization-related pelvic complications after nonselective angioembolization compared to that after selective angioembolization in patients with pelvic injury accompanying hemorrhage. Materials and Methods: Relevant articles were collected by searching the PubMed, EMBASE, and Cochrane databases until 24 June 2023. Meta-analyses were conducted using odds ratios (ORs) for binary outcomes. Quality assessment was conducted using the risk of bias tool in non-randomized studies of interventions. Results: Five studies examining 357 patients were included in the meta-analysis. Embolization-related pelvic complications did not significantly differ between patients with nonselective and selective angioembolization (OR 1.581, 95% confidence interval [CI] 0.592 to 4.225, I(2) = 0%). However, in-hospital mortality was more likely to be higher in the nonselective group (OR 2.232, 95% CI 1.014 to 4.913, I(2) = 0%) than in the selective group. In the quality assessment, two studies were found to have a moderate risk of bias, whereas two studies exhibited a serious risk of bias. Conclusions: Despite the favorable outcomes observed with nonselective angioembolization concerning embolization-related pelvic complications, determining the exact effect sizes was limited owing to the significant risk of bias and heterogeneity. Nonetheless, the low incidence of ischemic pelvic complications appears to be a promising result.
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The Impact of the Addition of a Virtual Reality Trainer on Skill Retention of Tourniquet Application for Hemorrhage Control Among Emergency Medical Technician Students: A Pilot Study
Arif A, Santana Felipes RC, Hoxhaj M, Light MB, Dadario NB, Cook B, Cataldo MJ, Jafri FN
Cureus. 2023;15(1):e34320
Abstract
INTRODUCTION Trauma is a leading cause of preventable death in the United States. Emergency Medical Technicians (EMTs) often arrive first at the scene of traumatic injuries to perform life-saving skills such as tourniquet placement. While current EMT courses teach and test tourniquet application, studies have shown efficacy and retention of EMT skills such as tourniquet placement decay over time, with educational interventions needed to improve retention of skills. METHODS A prospective randomized pilot study was conducted to determine differences in retention of tourniquet placement among 40 EMT students after initial training. Participants were randomly assigned to either a virtual reality (VR) intervention or a control group. The VR group received instruction from a refresher VR program 35 days after initial training as a supplement to their EMT course. Both the VR and control participants' tourniquet skills were assessed 70 days after initial training by blinded instructors. Results: There was no significant difference in correct tourniquet placement between both groups (Control, 63% vs Intervention, 57%, p = 0.57). It was found that 9/21 participants (43%) in the VR intervention group failed to correctly apply the tourniquet while 7/19 of the control participants (37%) failed in tourniquet application. Additionally, the VR group was more likely to fail the tourniquet application due to improper tightening than the control group during the final assessment (p = 0.04). Conclusion: In this pilot study, using a VR headset in conjunction with in-person training did not improve the efficacy and retention of tourniquet placement skills. Participants who received the VR intervention were more likely to have errors relating to haptics, rather than procedure-related errors.
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Admission CT radiomic signatures outperform hematoma volume in predicting baseline clinical severity and functional outcome in the ATACH-2 trial intracerebral hemorrhage population
Haider SP, Qureshi AI, Jain A, Tharmaseelan H, Berson ER, Zeevi T, Majidi S, Filippi CG, Iseke S, Gross M, et al
European journal of neurology. 2021
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Abstract
BACKGROUND Radiomics provides a framework for automated extraction of high-dimensional feature sets from medical images. We aimed to determine radiomics signature correlates of admission clinical severity and medium-term outcome from intracerebral hemorrhage (ICH) lesions on baseline head CTs. METHODS We used the ATACH-2 (Antihypertensive-Treatment-of-Acute-Cerebral-Hemorrhage-II) trial dataset. Patients included in this analysis (n=895) were randomly allocated to discovery (n=448) and independent validation (n=447) cohorts. We extracted 1130 radiomics features from hematoma lesions on baseline non-contrast head CTs and generated radiomics signatures associated with admission Glasgow Coma Scale (GCS), admission National Institutes of Health Stroke Scale (NIHSS), and 3-month modified Rankin Scale (mRS) scores. Spearman's correlation between radiomics signatures and corresponding target variables was compared with hematoma volume. RESULTS In the discovery cohort, radiomics signatures - compared to ICH volume - had significantly stronger association with admission GCS (0.47 vs 0.44, p=0.008), admission NIHSS (0.69 vs 0.57, p<0.001), and 3-month mRS scores (0.44 vs 0.32, p<0.001). Similarly, in independent validation, radiomics signatures - compared to ICH volume - had significantly stronger association with admission GCS (0.43 vs 0.41, p=0.02), NIHSS (0.64 vs 0.56, p<0.001), and 3-month mRS scores (0.43 vs 0.33, p<0.001). In multiple regression analysis adjusted for known predictors of ICH outcome, the radiomics signature was an independent predictor of 3-month mRS in both cohorts. CONCLUSIONS Limited by the enrollment criteria of the ATACH-2 trial, we showed that radiomics features quantifying hematoma texture, density and shape on baseline CT can provide imaging correlates for clinical presentation and medium-term outcome.
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Risk stratification with video capsule endoscopy leads to fewer hospital admissions in emergency department patients with low-risk to moderate-risk upper gastrointestinal bleed: A multicenter clinical trial
Meltzer AC, Limkakeng AT Jr, Gentile NT, Freeman JQ, Hall NC, Vargas NM, Fleischer DE, Malik Z, Kallus SJ, Borum ML, et al
Journal of the American College of Emergency Physicians open. 2021;2(5):e12579
Abstract
OBJECTIVE In US emergency departments (EDs), the physician has limited ability to evaluate for common and serious conditions of the gastrointestinal (GI) mucosa such as a bleeding peptic ulcer. Although many bleeding lesions are self-limited, the majority of these patients require emergency hospitalization for upper endoscopy (EGD). We conducted a clinical trial to determine if ED risk stratification with video capsule endoscopy (VCE) reduces hospitalization rates for low-risk to moderate-risk patients with suspected upper GI bleeding. METHODS We conducted a randomized controlled trial at 3 urban academic EDs. Inclusion criteria included signs of upper GI bleeding and a Glasgow Blatchford score <6. Patients were randomly assigned to 1 of the following 2 treatment arms: (1) an experimental arm that included VCE risk stratification and brief ED observation versus (2) a standard care arm that included admission for inpatient EGD. The primary outcome was hospital admission. Patients were followed for 7 and 30 days to assess for rebleeding events and revisits to the hospital. RESULTS The trial was terminated early as a result of low accrual. The trial was also terminated early because of a need to repurpose all staff to respond to the coronavirus disease 2019 pandemic. A total of 24 patients were enrolled in the study. In the experimental group, 2/11 (18.2%) patients were admitted to the hospital, and in the standard of care group, 10/13 (76.9%) patients were admitted to the hospital (P = 0.012). There was no difference in safety on day 7 and day 30 after the index ED visit. CONCLUSIONS VCE is a potential strategy to decrease admissions for upper GI bleeding, though further study with a larger cohort is required before this approach can be recommended.
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Frequency and Impact of Bleeding on Outcome in Patients With Cardiogenic Shock
Freund A, Jobs A, Lurz P, Feistritzer HJ, de Waha-Thiele S, Meyer-Saraei R, Montalescot G, Huber K, Noc M, Windecker S, et al
JACC Cardiovasc Interv. 2020;13(10):1182-1193
Abstract
OBJECTIVES This study sought to determine frequency, associated factors, and impact of bleeding in infarct-related cardiogenic shock. BACKGROUND Early revascularization is associated with improved survival in patients with acute myocardial infarction complicated by cardiogenic shock. On the downside, invasive treatment and accompanying antithrombotic therapies are associated with an increased bleeding risk. Prospective data assessing the incidence, severity, risk factors, and prognostic implication of bleeding in patients with cardiogenic shock are scarce. METHODS As a pre-defined subanalysis of the CULPRIT-SHOCK (PCI Strategies in Patients with Acute Myocardial Infarction and Cardiogenic Shock) randomized trial, we examined distribution of bleeding events in 684 patients with infarct-related cardiogenic shock and compared patients with any bleeding to those without. RESULTS A total of 21.5% patients experienced at least 1 bleeding event until 30 days after randomization. The vast majority of bleeding (57%) occurred within the first 2 days of hospitalization. Patients with bleeding had prolonged catecholamine treatment and mechanical ventilation and there was a significant association with sepsis, peripheral ischemic complications, new atrial fibrillation, and ventricular fibrillation. In multivariable analysis, bleeding was associated with a significantly higher mortality (hazard ratio: 2.11; 95% confidence interval: 1.63 to 2.75; p < 0.0001). Treatment with active mechanical support by extracorporeal membrane oxygenation or Impella emerged as the major risk factor for bleeding. CONCLUSIONS Risk of bleeding in infarct-related cardiogenic shock is high and associated with increased mortality.
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Negative pressure wound therapy versus standard treatment in patients with acute conflict-related extremity wounds: a pragmatic, multisite, randomised controlled trial
Älgå, A., Haweizy, R., Bashaireh, K., Wong, S., Lundgren, K. C., von Schreeb, J., Malmstedt, J.
The Lancet. Global Health. 2020;8(3):e423-e429
Abstract
BACKGROUND In armed conflict, injuries among civilians are usually complex and commonly affect the extremities. Negative pressure wound therapy (NPWT) is an alternative to standard treatment of acute conflict-related extremity wounds. We aimed to compare the safety and effectiveness of NPWT with that of standard treatment. METHODS In this pragmatic, randomised, controlled superiority trial done at two civilian hospitals in Jordan and Iraq, we recruited patients aged 18 years or older, presenting with a conflict-related extremity wound within 72 h after injury. Participants were assigned (1:1) to receive either NPWT or standard treatment. We used a predefined, computer-generated randomisation list with three block sizes. Participants and their treating physicians were not masked to treatment allocation. The primary endpoint was wound closure by day 5. The coprimary endpoint was net clinical benefit, defined as a composite of wound closure by day 5 and freedom from any bleeding, wound infection, sepsis, or amputation of the index limb. Analysis was by intention to treat. The trial is registered with ClinicalTrials.gov, number NCT02444598, and is closed to accrual. FINDINGS Between June 9, 2015, and Oct 24, 2018, 174 patients were randomly assigned to either the NPWT group (n=88) or the standard treatment group (n=86). Five patients in the NPWT group and four in the standard treatment group were excluded from the intention-to-treat analysis. By day 5, 41 (49%) of 83 participants in the NPWT group and 49 (60%) of 82 participants in the standard treatment group had closed wounds, with an absolute difference of 10 percentage points (95% CI -5 to 25, p=0·212; risk ratio [RR] 0·83, 95% CI 0·62 to 1·09). Net clinical benefit was seen in 33 (41%) of 81 participants in the NPWT group and 34 (44%) of 78 participants in the standard treatment group, with an absolute difference of 3 percentage points (95% CI -12 to 18, p=0·750; RR 0·93, 95% CI 0·65 to 1·35). There was one in-hospital death in the standard treatment group and none in the NPWT group. The proportion of participants with sepsis, bleeding leading to blood transfusion, and limb amputation did not differ between groups. INTERPRETATION NPWT did not yield superior clinical outcomes compared with standard treatment for acute conflict-related extremity wounds. The results of this study not only question the use of NPWT, but also question the tendency for new and costly treatments to be introduced into resource-limited conflict settings without supporting evidence for their effectiveness. This study shows that high-quality, randomised trials in challenging settings are possible, and our findings support the call for further research that will generate context-specific evidence. FUNDING The Stockholm County Council, the Swedish National Board of Health and Welfare, and Médecins Sans Frontières.
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Effect of two tourniquet techniques on peripheral intravenous cannulation success: A randomized controlled trial
Tran T, Lund SB, Nichols MD, Kummer T
The American journal of emergency medicine. 2019
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Abstract
OBJECTIVES Peripheral intravenous (IV) cannulation is the most common procedure performed in the emergency department (ED). Elastic tourniquets (ETs) and blood pressure cuffs (BPCs) are frequently used for venodilation. Although BPCs lead to increased venodilation and decreased compressibility, it is unclear whether this translates into a meaningful patient-centered outcome. This study aimed to determine whether one method is superior for success on the first attempt. METHODS This was a prospective, single-blinded, randomized controlled trial in the ED of a tertiary care center. A convenience sample of adult patients was randomly assigned to an ET or BPC with a cover concealing the type of tourniquet. The primary outcome was success rate on the first attempt. Secondary outcomes were number of attempts, number of providers, and rate of rescue techniques. RESULTS Of the 121 patients enrolled, 119 qualified for analysis. In the ET group, 42 of 59 patients (71%) had successful IV cannulation on first attempt compared with 43 of 60 (72%) in the BPC group (P=.95). The number of attempts (P=.87), number of nurses (P=.67), and use of rescue techniques (P=.32) did not differ significantly. A history of difficult IV access and site other than the antecubital vein were associated with decreased success. CONCLUSIONS ETs and BPCs performed similarly in providing venodilation for successful peripheral IV cannulation. History of difficult IV access and IV site are important factors in determining the likelihood of success.
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Effect of Aspiration and Evaluation of Gastric Residuals on Intestinal Inflammation, Bleeding, and Gastrointestinal Peptide Level
Parker LA, Weaver M, Murgas Torrazza RJ, Shuster J, Li N, Krueger C, Neu J
The Journal of pediatrics. 2019
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OBJECTIVE To determine the effect of gastric residual aspiration and evaluation on preterm very low birth weight infants' gastrointestinal function, intestinal inflammation, and gastrointestinal mucosal bleeding. STUDY DESIGN This single-center, randomized trial compared omission of gastric residuals vs prefeed gastric residuals in 143 infants ≤32 weeks of gestation with a birthweight of ≤1250 g for 6 weeks after birth. Serum levels of gastrin and motilin were collected between 14 and 21 days of life. Stools were collected at 3 and 6 weeks of age and analyzed for calprotectin and S100A12 levels. All stools were tested for occult blood for 6 weeks. RESULTS Means for gastrin (P = .999) and motilin (P = .694) were similar between groups and there were no statistically significant differences in adjusted means for transformed calprotectin (P = .580), and S100A12 (P = .212). Both calprotectin (P = .003) and S100A12 (P = .002) increased from week 3 to week 6. The mean percentage of stools positive for occult blood (P = .888) were similar between the groups. CONCLUSIONS Gastrointestinal function, intestinal inflammation, and gastrointestinal mucosal bleeding were similar whether aspiration and evaluation of gastric residuals were eliminated or not, suggesting routinely evaluating gastric residuals before every feeding may be unnecessary. TRIAL REGISTRATION CLINICALTRIALS.GOV:: NCT01863043.
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Single Versus Double Tourniquet Technique for Ultrasound-Guided Venous Catheter Placement
Price J, Xiao J, Tausch K, Hang B, Bahl A
The western journal of emergency medicine. 2019;20(5):719-725
Abstract
INTRODUCTION Peripheral, ultrasound-guided intravenous (IV) access occurs frequently in the emergency department, but certain populations present unique challenges for successfully completing this procedure. Prior research has demonstrated decreased compressibility under double tourniquet technique (DT) compared with single tourniquet (ST). We hypothesized that catheters inserted under DT method would have a higher first-stick success rate compared with those inserted under ST method. METHODS We randomized 100 patients with a history of difficult IV access, as defined by past ultrasound IV, prior emergency visit with two or more attempts required for vascular access, history of IV drug abuse, history of end stage renal disease on hemodialysis or obesity, to ultrasound-guided IV placement under either DT or ST method. We measured the vein characteristics measured under ultrasound, and recorded the number of attempts and location of attempts at vascular access. RESULTS Of an initial 100 patients enrolled, we analyzed a total of 99 with 48 placed under ST and 51 placed under DT. Attending physicians inserted 41.7% of ST and 41.2% of DT, with non-attending inserters (including residents, nurses, and technicians) inserted the remainder. First-stick success rate was observed at 64.3% in ST and 66.7% in DT (p=0.93). Attendings had an overall higher first-stick success rate (95.1%) compared to non-attending inserters (65.5%) (p=<0.001). The average vein depth measured in ST was 0.73 centimeters (cm) compared with 0.87 cm in DT (p=0.02). CONCLUSION DT technique did not produce a measureable increase in first-stick success rate compared to ST, including after adjusting for level of training of inserter. However, a significant difference in average vein depth between the study arms may have limited the reliability of our overall results. Future studies controlling for this variable may be required to more accurately compare these two techniques.
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Pre-hospital Hemorrhagic Control Effectiveness of Axiostat(R) Dressing Versus Conventional Method in Acute Hemorrhage Due to Trauma
Kabeer M, Venugopalan PP, Subhash VC
Cureus. 2019;11(8):e5527
Abstract
Accidents and trauma are one of the leading causes of death and disability throughout the world. In developing countries like India where emergency trauma care is still emerging, it accounts for almost 10% of deaths every year. Lack of adequate pre-hospital care and uncontrolled bleeding from the wound site are stated to be the prominent reasons for such deaths. The aim of this study was to evaluate the efficacy of a novel chitosan-based haemostatic dressing, Axiostat(R) (Axio Biosolutions Private Ltd., Gujarat, India), as a hemorrhage control device in the ambulance setting. A total of 104 patients with bleeding scalp wounds were randomly allocated into two treatment groups while transporting them to the hospital. Patients in Group I were treated with Axiostat(R) chitosan haemostatic dressing (n = 47), while a conventional cotton gauze dressing was used in Group II (n = 57). A standard procedure was followed to apply the dressing on bleeding wounds and time to achieve haemostasis, the amount of blood loss, the number of patients with haemostasis, the occurrence of rebleeding, and other side effects were noted. The mean age of the patients was 40 years and the majority of patients were male - 73 (70%). Most of the wounds were lacerations with venous bleeding. Haemostasis time was 4.68 +/- 1.04 minutes and 18.56 +/- 5.04 minutes in the Axiostat(R) and cotton gauze groups, respectively. The use of Axiostat(R) significantly reduced the time to haemostasis (p < 0.0001). A significant reduction in blood loss was observed with the application of Axiostat(R). Successful haemostasis was achieved in 94% of patients in the Axiostat(R) group and 74% patients in cotton gauze group, respectively (p < 0.05). Moreover, no side effects, such as tissue loss or rebleeding at time of removal, were seen with the use of Axiostat(R), while three patients in the cotton gauze group showed some side effects. Results show that Axiostat(R) enables rapid haemostasis and can prevent significant blood loss during emergency trauma and accidents. Additionally, it also allows for easier removal from the wound site without leaving any residue, which helps in rendering the wound clean. In conclusion, the study successfully demonstrates the potential of Axiostat(R) as a first-line intervention in controlling acute haemorrhage in emergency care.