Impact thromboelastometry (ITEM) for point-of-injury detection of trauma-induced coagulopathy: a pilot study.

BACKGROUND: Acute coagulopathy of trauma is associated with high mortality and extensive use of blood products. Hemostatic resuscitation, the early administration of blood products with higher ratios of procoagulant components, may improve trauma outcomes in select cases, but can also worsen outcome if inappropriately used. Evolving approaches to hemostatic resuscitation utilize viscoelastic tests to provide a more rational basis for choosing blood component therapy regimens, but these tests are logistically rigorous. We hypothesized that coagulopathy could be detected by the failure of blood clots to remain intact when subjected to a predefined impact force. METHODS: We aim to develop a point-of-injury test for coagulopathy. We created coagulopathic blood using an ex vivo normal saline (NS) dilution model and allowed blood of varying dilutions to clot, then examined the behavior of the clotted blood when subjected to a uniform gravitationally induced sheer force. RESULTS: Clots created from coagulopatic blood (diluted to ≤50% with NS) failed under gravitational challenge at a significantly higher rate than non-coagulopathic blood dilutions. DISCUSSION: Impact thromboelastometry (ITEM) represents a simple, logistically lean method for detecting dilutional coagulopathy that may facilitate detection of trauma-induced coagulopathy. ITEM may thus function as a point-of-injury or point-of-care screening test for the presence of coagulopathy. LEVEL OF EVIDENCE: Diagnostic studies, Level IV.

Mitigate, adapt, or suffer: Peak oil's new disaster paradigm.

OBJECTIVES: To address the impacts of peak oil (PO) on human health and to propose new public health preparedness models and measures mandated by these impacts. DESIGN: Review of relevant literature. Articles were obtained by searching the PubMed database (including manual searches using "related citations" tool) plus Google and Google Scholar search engines using terms such as "peak oil," "energy scarcity," "human health," "public health," and "preparedness." RESULTS: Forty-six journal articles were reviewed. CONCLUSIONS: The projections about PO are concerning, as illustrated by minor PO events in the recent past. There are many opportunities for devising beneficial solutions within healthcare to mitigate the effects of PO. It is essential for disaster medicine professionals to become aware of PO and to advocate for change in clinical practice with patients as well as policy leaders. If we fail to mitigate the effects of PO on healthcare, we will be left with the less pleasant options of adapting to PO or suffering its effects.

Amyand hernia: a case of an unusual inguinal herniace.

Amyand hernia, named for the first person to describe an inguinal hernia containing the vermiform appendix, is an uncommon variant of an inguinal hernia. Presence of the appendix in the sac complicates the management of inguinal hernias. The appendix may be more prone to rupture when contained within a hernia sac, and herniation of an inflamed appendix into the scrotum can mimic an acute scrotum. A 50-year-old man presented with right lower quadrant abdominal pain associated with chills and anorexia. Physical examination revealed right lower quadrant tenderness and a right inguinal mass without associated skin changes. Laboratories were normal. A plain abdominal computed tomography scan for acute appendicitis showed an indirect right inguinal hernia with the appendix contained within the sac, which was incarcerated. Surgical consultation was obtained. The patient taken to the operating room, and his appendix was removed. The hernia was coincidentally repaired, and the patient was discharged soon thereafter. In cases suggestive of acute appendicitis complicating an inguinal hernia, the diagnosis of this unusual variant must be considered.

Tourniquets: a review of current use with proposals for expanded prehospital use.

The use of arterial tourniquets in prehospital emergency care has been fraught with controversy and superstition for many years despite the potential utility of these tools. This review examines this controversy in the context of the history of the tourniquet as well as its recent use in surgery and modern battlefield casualty care. Safe prehospital tourniquet use is widespread in the military and is based on sound physiologic data and clinical experience from the surgical use of tourniquets. The physiologic, pathophysiologic, and clinical underpinnings of safe tourniquet use are reviewed here, along with a discussion of alternatives to tourniquets. Prehospital settings in which tourniquets are useful include tactical emergency medical services (EMS) and other law enforcement environments as well as disaster and mass casualty incidents. Beyond this, we present arguments for tourniquet use in more routine EMS settings, in which it may be beneficial but has heretofore been considered inappropriate. Protocols that foster safe, effective prehospital tourniquet use in these settings are then presented. Finally, we discuss future directions in which tourniquet research and other initiatives will further enhance the safe, rational use of this potentially life-saving tool.