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1.
West J Emerg Med ; 22(4): 951-957, 2021 Jun 29.
Article in English | MEDLINE | ID: covidwho-1572897

ABSTRACT

INTRODUCTION: Trauma is the leading cause of death for young Americans. Increased school violence, combined with an emphasis on early hemorrhage control, has boosted demand to treat injuries in schools. Meanwhile, coronavirus disease 2019 (COVID-19) has made educating the public about trauma more difficult. A federally funded high school education program in development, called First Aid for Severe Trauma™ (FAST™), will teach students to aid the severely injured. The program will be offered in instructor-led, web-based, and blended formats. We created a program to prepare high school teachers to become FAST instructors via "virtual" in-person (VIP) instruction. We used a webinar followed by VIP skills practice, using supplies shipped to participants' homes. To our knowledge, no prior studies have evaluated this type of mass, widely distributed, VIP education. METHODS: This study is a prospective, single-arm, educational cohort study. We enrolled a convenience sample of all high school teachers attending FAST sessions at the Health Occupations Students of America-Future Health Professionals International Leadership Conference. Half of the participants were randomized to complete the Stop the Bleed Education Assessment Tool (SBEAT) prior to the webinar, and the other completed it afterward; SBEAT is a validated tool to measure learning of bleeding competencies. We then performed 76 VIP video-training sessions from June-August 2020. The FAST instructors assessed each participant's ability to apply a tourniquet and direct pressure individually, then provided interactive group skills training, and finally re-evaluated each participant's performance post-training. RESULTS: A total of 190 (96%) participants successfully applied a tourniquet after VIP training, compared to 136 (68%) prior to training (P < 0.001). Participants significantly improved their ability to apply direct pressure: 116 (56%) pre-assessment vs 204 (100%) post-assessment (P < 0.001). The mean score for the SBEAT increased significantly from pre-training to post-training: 2.09 with a standard deviation (SD) of 0.97 to 2.55 post-training with a SD of 0.72 (P < 0.001). CONCLUSION: This study suggests that a webinar combined with VIP training is effective for teaching tourniquet and direct-pressure application skills, as well as life-threatening bleeding knowledge. VIP education may be useful for creating resuscitative medicine instructors from distributed locations, and to reach learners who cannot attend classroom-based instruction.


Subject(s)
COVID-19 , First Aid , Cohort Studies , Hemorrhage/therapy , Humans , Prospective Studies , United States
2.
Br J Haematol ; 196(3): 566-576, 2022 02.
Article in English | MEDLINE | ID: covidwho-1462745

ABSTRACT

Bleeding and thrombosis are major complications in patients supported with extracorporeal membrane oxygenation (ECMO). In this multicentre observational study of 152 consecutive patients (≥18 years) with severe COVID-19 supported by veno-venous (VV) ECMO in four UK commissioned centres during the first wave of the COVID-19 pandemic (1 March to 31 May 2020), we assessed the incidence of major bleeding and thrombosis and their association with 180-day mortality. Median age (range) was 47 years (23-65) and 75% were male. Overall, the 180-day survival was 70·4% (107/152). The rate of major bleeding was 30·9% (47/152), of which intracranial bleeding (ICH) was 34% (16/47). There were 96 thrombotic events (63·1%) consisting of venous 44·7% [68/152 of which 66·2% were pulmonary embolism (PE)], arterial 18·6% (13/152) and ECMO circuit thrombosis 9·9% (15/152). In multivariate analysis, only raised lactate dehydrogenase (LDH) at the initiation of VV ECMO was associated with an increased risk of thrombosis [hazard ratio (HR) 1·92, 95% CI 1·21-3·03]. Major bleeding and ICH were associated with 3·87-fold (95% CI 2·10-7·23) and 5·97-fold [95% confidence interval (CI) 2·36-15·04] increased risk of mortality and PE with a 2·00-fold (95% CI1·09-3·56) risk of mortality. This highlights the difficult balancing act often encountered when managing coagulopathy in COVID-19 patients supported with ECMO.


Subject(s)
COVID-19 , Extracorporeal Membrane Oxygenation , Hemorrhage , SARS-CoV-2/metabolism , Thrombosis , Adult , COVID-19/blood , COVID-19/mortality , COVID-19/therapy , Disease-Free Survival , Female , Hemorrhage/blood , Hemorrhage/mortality , Hemorrhage/therapy , Humans , Male , Middle Aged , Survival Rate , Thrombosis/blood , Thrombosis/mortality , Thrombosis/therapy , United Kingdom/epidemiology
3.
Postgrad Med ; 133(8): 899-911, 2021 Nov.
Article in English | MEDLINE | ID: covidwho-1390265

ABSTRACT

INTRODUCTION: COVID-19-associated coagulopathy (CAC) is a well-recognized hematologic complication among patients with severe COVID-19 disease, where macro- and micro-thrombosis can lead to multiorgan injury and failure. Major societal guidelines that have published on the management of CAC are based on consensus of expert opinion, with the current evidence available. As a result of limited studies, there are many clinical scenarios that are yet to be addressed, with expert opinion varying on a number of important clinical issues regarding CAC management. METHODS: In this review, we utilize current societal guidelines to provide a framework for practitioners in managing their patients with CAC. We have also provided three clinical scenarios that implement important principles of anticoagulation in patients with COVID-19. CONCLUSION: Overall, decisions should be made on acase by cases basis and based on the providers understanding of each patient's medical history, clinical course and perceived risk.


Subject(s)
Anticoagulants/therapeutic use , Blood Coagulation Disorders/therapy , COVID-19/complications , Practice Guidelines as Topic , Thromboembolism/therapy , Thrombosis/therapy , Anticoagulants/adverse effects , Biomarkers/blood , Blood Coagulation Disorders/diagnosis , Blood Coagulation Disorders/virology , Drug Monitoring , Fibrinolytic Agents/therapeutic use , Hemorrhage/chemically induced , Hemorrhage/therapy , Heparin/therapeutic use , Humans , Prevalence , Thromboembolism/diagnosis , Thromboembolism/epidemiology , Thromboembolism/virology , Thrombosis/diagnosis , Thrombosis/epidemiology , Thrombosis/virology
5.
Br J Haematol ; 195(3): 365-370, 2021 11.
Article in English | MEDLINE | ID: covidwho-1255364

ABSTRACT

There is concern that COVID-19 vaccination may adversely affect immune thrombocytopenia (ITP) patients. Fifty-two consecutive chronic ITP patients were prospectively followed after COVID-19 vaccination. Fifteen percent had no worsening of clinical symptoms but no post-vaccination platelet count; 73% had no new symptoms and no significant platelet count decline. However, 12% had a median platelet count drop of 96% within 2-5 days post vaccination with new bleeding symptoms; after rescue therapy with corticosteroids +/- intravenous immunoglobulin (IVIG), platelets recovered to >30 × 109 /l a median three days later. ITP exacerbation occurred independently of remission status, concurrent ITP treatment, or vaccine type. Safety of a second vaccine dose needs careful assessment.


Subject(s)
COVID-19 Vaccines/adverse effects , COVID-19/prevention & control , Hemorrhage/etiology , Purpura, Thrombocytopenic, Idiopathic/complications , Adrenal Cortex Hormones/therapeutic use , Adult , Aged , COVID-19/complications , COVID-19/pathology , Female , Follow-Up Studies , Hemorrhage/pathology , Hemorrhage/therapy , Humans , Immunoglobulins, Intravenous/therapeutic use , Male , Middle Aged , Platelet Count , Prospective Studies , Purpura, Thrombocytopenic, Idiopathic/pathology , Purpura, Thrombocytopenic, Idiopathic/therapy , Severity of Illness Index , Young Adult
9.
J Surg Res ; 264: 469-473, 2021 08.
Article in English | MEDLINE | ID: covidwho-1174400

ABSTRACT

BACKGROUND: The Stop the Bleed (STB) campaign was developed in part to educate the lay public about hemorrhage control techniques aimed at reducing preventable trauma deaths. Studies have shown this training increases bystanders' confidence and willingness to provide aid. One high-risk group might be better solicited to take the course: individuals who have been a victim of previous trauma, as high rates of recidivism after trauma are well-established. Given this group's risk for recurrent injury, we evaluated their attitudes toward STB concepts. METHODS: We surveyed trauma patients admitted to 3 urban trauma centers in Baltimore from January 8, 2020 to March 14, 2020. The survey was terminated prematurely due to the COVID-19 pandemic. Trauma patients hospitalized on any inpatient unit were invited to complete the survey via an electronic tablet. The survey asked about demographics, prior exposure to life-threatening hemorrhage and first aid training, and willingness to help a person with major bleeding. The Johns Hopkins IRB approved waiver of consent for this study. RESULTS: Fifty-six patients completed the survey. The majority of respondents had been hospitalized before (92.9%) and had witnessed severe bleeding (60.7%). The majority had never taken a first aid course (60.7%) nor heard of STB (83.9%). Most respondents would be willing to help someone with severe bleeding form a car crash (98.2%) or gunshot wound (94.6%). CONCLUSIONS: Most patients admitted for trauma had not heard about Stop the Bleed, but stated willingness to respond to someone injured with major bleeding. Focusing STB education on individuals at high-risk for trauma recidivism may be particularly effective in spreading the message and skills of STB.


Subject(s)
First Aid/methods , Health Education/methods , Hemorrhage/therapy , Hemostatic Techniques , Wounds and Injuries/therapy , Accidents, Traffic , Adolescent , Adult , Aged , Baltimore , Cohort Studies , Female , Firearms , Health Education/statistics & numerical data , Health Knowledge, Attitudes, Practice , Hemorrhage/diagnosis , Hemorrhage/etiology , Humans , Male , Middle Aged , Severity of Illness Index , Surveys and Questionnaires/statistics & numerical data , Wounds and Injuries/complications , Wounds and Injuries/diagnosis , Young Adult
11.
Am J Emerg Med ; 47: 316.e1-316.e3, 2021 Sep.
Article in English | MEDLINE | ID: covidwho-1141562

ABSTRACT

While primarily a respiratory illness, infection with the novel coronavirus (COVID-19) is associated with pathologic changes in coagulation, characterized by both thromboembolic and bleeding events. We present the case of a 22-year-old female diagnosed with renal angiomyolipoma (AML) rupture 2 weeks after COVID-19 infection, ultimately requiring admission for hemorrhage control via endovascular embolization. Emergency medicine physicians should maintain a high index of suspicion for renal AML rupture and other spontaneous bleeding events in patients with recent COVID-19 infection due to a possible correlation between the two.


Subject(s)
Angiomyolipoma/complications , COVID-19/complications , Hemorrhage/etiology , Kidney Neoplasms/complications , Angiomyolipoma/diagnostic imaging , Angiomyolipoma/therapy , Embolization, Therapeutic/methods , Female , Hemorrhage/diagnostic imaging , Hemorrhage/therapy , Humans , Kidney Neoplasms/diagnostic imaging , Kidney Neoplasms/therapy , Rupture , SARS-CoV-2 , Young Adult
12.
Chin J Traumatol ; 24(2): 63-68, 2021 Mar.
Article in English | MEDLINE | ID: covidwho-1093003

ABSTRACT

Throughout the past 2020, the pandemic COVID-19 has caused a big global shock, meanwhile it brought a great impact on the public health network. Trauma emergency system faced a giant challenge and how to manage trauma under the pandemic of COVID-19 was widely discussed. However, the trauma treatment of special population (geriatric patients and patients taking anticoagulant drugs) has received inadequate attention. Due to the high mortality following severe traumatic hemorrhage, hemostasis and trauma-induced coagulopathy are the important concerns in trauma treatment. Sepsis is another topic should not be ignored when we talking about trauma. COVID-19 itself is a special kind of sepsis, and it may even be called as serious systemic infection syndrome. Sepsis has been become a serious problem waiting to be solved urgently no matter in the fields of trauma, or in intensive care and infection, etc. This article reviewed the research progress in areas including trauma emergency care, trauma bleeding and coagulation, geriatric trauma and basic research of trauma within 2020.


Subject(s)
COVID-19 , Emergency Medical Services , Pandemics , Public Health , Trauma Centers , Wounds and Injuries/therapy , Community Networks , Disseminated Intravascular Coagulation/etiology , Disseminated Intravascular Coagulation/prevention & control , Disseminated Intravascular Coagulation/therapy , Female , Health Services for the Aged , Hemorrhage/etiology , Hemorrhage/therapy , Hemostasis , Humans , Male , Sepsis/etiology , Sepsis/therapy , Time Factors , Wounds and Injuries/complications
13.
Int J Artif Organs ; 45(2): 239-242, 2022 Feb.
Article in English | MEDLINE | ID: covidwho-1052373

ABSTRACT

INTRODUCTION: COVID-19 has been associated with increased risk of thrombosis, heparin resistance and coagulopathy in critically ill patients admitted to intensive care. We report the incidence of thrombotic and bleeding events in a single center cohort of 30 consecutive patients with COVID-19 supported by veno-venous extracorporeal oxygenation (ECMO) and who had a whole body Computed Tomography Scanner (CT) on admission. METHODOLOGY: All patients were initially admitted to other hospitals and later assessed and retrieved by our ECMO team. ECMO was initiated in the referral center and all patients admitted through our CT scan before settling in our intensive care unit. Clinical management was guided by our institutional ECMO guidelines, established since 2011 and applied to at least 40 patients every year. RESULTS: We diagnosed a thrombotic event in 13 patients on the initial CT scan. Two of these 13 patients subsequently developed further thrombotic complications. Five of those 13 patients had a subsequent clinically significant major bleeding. In addition, two patients presented with isolated intracranial bleeds. Of the 11 patients who did not have baseline thrombotic events, one had a subsequent oropharyngeal hemorrhage. When analyzed by ROC analysis, the area under the curve for % time in intended anticoagulation range did not predict thrombosis or bleeding during the ECMO run (0.36 (95% CI 0.10-0.62); and 0.51 (95% CI 0.25-0.78); respectively). CONCLUSION: We observed a high prevalence of VTE and a significant number of hemorrhages in these severely ill patients with COVID-19 requiring veno-venous ECMO support.


Subject(s)
COVID-19 , Extracorporeal Membrane Oxygenation , Thrombosis , Anticoagulants/adverse effects , Extracorporeal Membrane Oxygenation/adverse effects , Hemorrhage/etiology , Hemorrhage/therapy , Humans , Retrospective Studies , SARS-CoV-2 , Thrombosis/epidemiology , Thrombosis/etiology
16.
Transfusion ; 60(12): 2793-2800, 2020 12.
Article in English | MEDLINE | ID: covidwho-755264

ABSTRACT

Civilian and military guidelines recommend balanced transfusion to patients with life-threatening bleeding. Early start of transfusion has shown improved survival. Thus, a balanced blood inventory must be available in all levels of health care to ensure early stabilization and damage control resuscitation of patients with bleeding. Whole blood has been reintroduced as a blood product for massive bleeding situations because it affords plasma, red blood cells, and platelets in a balanced ratio in a logistically advantageous way. In this article, we describe how to establish a whole blood-based blood preparedness program in a small rural hospital with limited resources. We present an implementation tool kit, which includes discussions on whole blood program strategies and the process of developing detailed procedures on donor selection, collection, storage, and transfusion management of whole blood. The importance of training and audit of the routines is highlighted, and establishment of an emergency walking blood bank is discussed. We conclude that implementation of a whole blood program is achievable in small rural hospitals and recommend that rural health care facilities at all treatment levels enable early balanced transfusion for patients with life-threatening bleeding by establishing protocols for whole blood-based preparedness.


Subject(s)
Blood Banks , Blood Component Transfusion , Donor Selection , Hemorrhage/therapy , Hospitals, Rural , Resuscitation , Hemorrhage/blood , Humans
19.
Semin Thromb Hemost ; 47(4): 351-361, 2021 Jun.
Article in English | MEDLINE | ID: covidwho-885548

ABSTRACT

Venous thromboembolism (VTE) is common in patients with coronavirus disease-2019 (COVID-19). However, limited data exist on patient characteristics, treatments, and outcomes. To describe the clinical characteristics, treatment patterns, and short-term outcomes of patients diagnosed with VTE during hospitalization for COVID-19. This is a prospective multinational study of patients with incident VTE during the course of hospitalization for COVID-19. Data were obtained from the Registro Informatizado de la Enfermedad TromboEmbólica (RIETE) registry. All-cause mortality, VTE recurrences, and major bleeding during the first 10 days were separately investigated for patients in hospital wards versus those in intensive care units (ICUs). As of May 03, 2020, a total number of 455 patients were diagnosed with VTE (83% pulmonary embolism, 17% isolated deep vein thrombosis) during their hospital stay; 71% were male, the median age was 65 (interquartile range, 55-74) years. Most patients (68%) were hospitalized in medical wards, and 145 in ICUs. Three hundred and seventeen (88%; 95% confidence interval [CI]: 84-91%) patients were receiving thromboprophylaxis at the time of VTE diagnosis. Most patients (88%) received therapeutic low-molecular-weight heparin, and 15 (3.6%) received reperfusion therapies. Among 420 patients with complete 10-day follow-up, 51 (12%; 95% CI: 9.3-15%) died, no patient recurred, and 12 (2.9%; 95% CI: 1.6-4.8%) experienced major bleeding. The 10-day mortality rate was 9.1% (95% CI: 6.1-13%) among patients in hospital wards and 19% (95% CI: 13-26%) among those in ICUs. This study provides characteristics and early outcomes of patients diagnosed with acute VTE during hospitalization for COVID-19. Additional studies are needed to identify the optimal strategies to prevent VTE and to mitigate adverse outcomes associated.


Subject(s)
COVID-19 , Heparin, Low-Molecular-Weight/administration & dosage , Hospital Mortality , Registries , Venous Thromboembolism , Adult , Aged , Aged, 80 and over , COVID-19/complications , COVID-19/diagnosis , COVID-19/mortality , COVID-19/therapy , Female , Follow-Up Studies , Hemorrhage/etiology , Hemorrhage/mortality , Hemorrhage/therapy , Humans , Male , Middle Aged , Prospective Studies , SARS-CoV-2 , Venous Thromboembolism/diagnosis , Venous Thromboembolism/etiology , Venous Thromboembolism/mortality , Venous Thromboembolism/therapy
20.
Transfusion ; 61(1): 72-77, 2021 01.
Article in English | MEDLINE | ID: covidwho-838822

ABSTRACT

BACKGROUND: The COVID-19 pandemic has placed great strain on blood resources. In an effort to extend platelet (PLT) shelf life and minimize waste, our institution transitioned room temperature to cold-stored PLTs for administration to bleeding patients. STUDY DESIGN AND METHODS: We describe the administrative and technical processes involved in transitioning room temperature PLTs to cold storage in April 2020. Additionally, we describe the clinical utilization of cold-stored PLTs in the first month of this practice change, with a focus on changes in PLT counts after transfusion, hemostasis, and safety outcomes. RESULTS: A total of 61 cold-stored PLT units were transfused to 40 bleeding patients, with a median (interquartile range [IQR]) of 1 (1-2) units per patient. The median age was 68 (59-73) years; 58% male. Median pretransfusion and posttransfusion PLTs counts were 88 (67-109) and 115 (93-145). A total of 95% of transfusions were administered in the operating room: 57% cardiac surgery, 20% vascular surgery, 8% general surgery, and 5% solid organ transplantation. Hemostasis was deemed to be adequate in all cases after transfusion. There were no transfusion reactions. One patient (3%) experienced a fever and infection within 5 days of transfusion, which was unrelated to transfusion. Median (IQR) hospital length of stay was 8.5 (6-17) days. Two patients (5%) died in the hospital of complications not related to transfusion. CONCLUSION: Cold-stored PLT utilization was associated with adequate hemostasis and no overt signal for patient harm. Conversion from room temperature to cold-stored PLTs may be one method of reducing waste in times of scarce blood inventories.


Subject(s)
Blood Platelets , Blood Preservation/methods , COVID-19/therapy , Platelet Transfusion/methods , Aged , Female , Hemorrhage/therapy , Humans , Male , Middle Aged , SARS-CoV-2/immunology , SARS-CoV-2/pathogenicity , Temperature
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