INHIBITORS OF INORGANIC POLYPHOSPHATE AND NUCLEIC ACIDS ATTENUATE IN VITRO THROMBIN GENERATION IN PLASMA FROM TRAUMA PATIENTS.

ABSTRACT: Background: Inorganic polyphosphate (polyP) is a procoagulant polyanion. We assessed the impact of polyP inhibition on thrombin generation after trauma using the novel polyP antagonists, macromolecular polyanion inhibitor 8 (MPI 8), and universal heparin reversal agent 8 (UHRA-8). Methods: Plasma thrombin generation (calibrated automated thrombogram, CAT), in 56 trauma patients and 39 controls +/- MPI 8 and UHRA-8 (50 µg/mL), was expressed as lag time (LT, minutes), peak height (PH, nM), and time to peak (ttPeak, minutes), with change in LT (ΔLT) and change in ttPeak (ΔttPeak) quantified. Results expressed in median and quartiles [Q1, Q3], Wilcoxon matched-pairs testing, P < 0.05 significant. Results: Trauma patients had greater baseline PH than controls (182.9 [121.0, 255.2]; 120.5 [62.1, 174.8], P < 0.001). MPI 8 treatment prolonged LT and ttPeak in trauma (7.20 [5.88, 8.75]; 6.46 [5.45, 8.93], P = 0.020; 11.28 [8.96, 13.14]; 11.00 [8.95, 12.94], P = 0.029) and controls (7.67 [6.67, 10.50]; 6.33 [5.33, 8.00], P < 0.001; 13.33 [11.67, 15.33]; 11.67 [10.33, 13.33], P < 0.001). UHRA-8 treatment prolonged LT and ttPeak and decreased PH in trauma (9.09 [7.45, 11.33]; 6.46 [5.45, 8.93]; 14.02 [11.78, 17.08]; 11.00 [8.95, 12.94]; 117.4 [74.5, 178.6]; 182.9 [121.0, 255.2]) and controls (9.83 [8.00, 12.33]; 6.33 [5.33, 8.00]; 16.67 [14.33, 20.00]; 11.67 [10.33, 13.33]; 55.3 [30.2, 95.9]; 120.5 [62.1, 174.8]), all P < 0.001. Inhibitor effects were greater for controls (greater ΔLT and ΔttPeak for both inhibitors, P < 0.001). Conclusion: PolyP inhibition attenuates thrombin generation, though to a lesser degree in trauma than in controls, suggesting that polyP contributes to accelerated thrombin generation after trauma.

Risk Factors for Gastrointestinal Leak after Perforated Peptic Ulcer Disease Operative Repair.

BACKGROUND: There are limited studies regarding the impact of post-operative leak on perforated peptic ulcer disease (PPUD) and conflicting results regarding routine drain placement in operative repair of PPUD. This study aims to identify risk factors for gastrointestinal leak after operative repair of PPUD to better guide intra-operative decisions about drain placement. METHODS: We performed a retrospective cohort study at a tertiary care center from 2008 to 2019, identifying 175 patients who underwent operative repair of PPUD. RESULTS: Patients who developed a leak (17%) were compared to patients who did not. Both hypoalbuminemia (albumin < 3.5 g/dL) (P = .03) and duodenal ulcers (P < .01) were identified as significant risk factors for leak. No significant difference was found between leak and no leak groups for AAST disease severity grade, repair technique, or pre-operative use of tobacco, alcohol, or steroids. Post-operative leaks were associated with prolonged hospital stay (29 days compared to 10, P < .01), increased complication rates (77% compared to 48%, P < .01), and increased re-operation rates (73% compared to 26%, <0.01). No difference was identified in patient characteristics or operative leak rates between patients who had drains placed at the index operation and those that did not. DISCUSSION: Leak after operative PPUD repair is associated with significant post-operative morbidity. Hypoalbuminemia and duodenal perforations are significant risk factors for post-operative leaks.

"Decompression of tension pneumothorax in a trauma patient -first use of a novel decompression colorimetric capnography device in human patient".

Tension pneumothorax is a common cause of mortality in trauma. Tension pneumothorax is the confinement of respired gases within the pleural cavity at increasing pressure resulting in hemodynamic collapse. Decompression is crucial in management. Emergency needle thoracostomy is a life-saving maneuver that allows atmospheric pressure equilibration and partial restoration of cardiac filling. Needle decompressions are usually performed under noisy, tense, and stressful circumstances, and objective assessment of success is difficult in the field. A device which is simple that objectively informs operators of successful decompression would be clinically useful. In previous work, we have demonstrated end-expiratory gas and gaseous composition of tension pneumothorax are similar due to increased carbon dioxide partial pressure relative to atmospheric gas composition. Therefore, a simple solution to objective needle decompression may be colorimetric capnography.We report a case of 58-year-old male treated by EMS following a motorcycle accident with left-sided chest pain, hypoxia, hypotension, and clinical findings of tension pneumothorax. Needle decompression with colorimetric capnography using the device indicated decompression of his tension pneumothorax, with appropriate temporizing success.

Prehospital Use of Ketamine: Effectiveness in Critically Ill and Injured Patients.

BACKGROUND: The military use of ketamine is well established. The benefits of prehospital civilian use have not been extensively reported. METHODS: A retrospective review was performed of patients with prehospital ketamine use in Mayo One's air and critical care ground transport. RESULTS: The medical records were reviewed from 2014 to 2016 to assess the efficacy of Ketamine. During this time frame, 158 (167 instances) patients were treated with ketamine for analgesia (38%), sedation (44%), or procedural (18%) use. The patient population had a mean age of 49 (range: 1-100), with 105 (67%) male patients. Indications included trauma (69%), which was further broken down into blunt (57%), penetrating (4%), and miscellaneous (8%), and medical illness (31%). The mean ketamine dose was 52.6 mg (range: 5-200 mg) via intravenous route. Ketamine was utilized in 61% of patients after other medications were ineffective. Overall success rate was 98%. Mean pain scale before and after ketamine use was 9/10 and 3/10, respectively. Ketamine use increased yearly from 21 (13%) in 2014, 56 (36%) in 2015, and 81 (51%) in 2016. CONCLUSION: Prehospital ketamine use is effective alone or in conjunction with other medications for analgesia, sedation, and procedural use in trauma and critically ill patients with minimal hemodynamic and respiratory consequences.

A multi-institutional study of hemostatic gauze and tourniquets in rural civilian trauma.

BACKGROUND: Life-threatening hemorrhage is a leading cause of preventable mortality in trauma patients. Since publication of the Hartford Consensus statement, there has been intense interest in civilian use of commercial hemostatic gauze and tourniquets. Although the military has studied their use on soldiers with wartime injuries, there are limited data on patient outcomes following civilian prehospital use and no data on the use in rural trauma. METHODS: We performed a multi-institutional retrospective analysis of clinical outcomes following prehospital use of QuikClot combat gauze (QC) and combat application tourniquets (CATs) from 2009 to 2014. The primary outcome measured was effectiveness. Secondary outcomes included morbidity, mortality, patients' demographics, injury characteristics, and hospital outcomes. RESULTS: Between 2009 and 2014, 95 patients were managed by prehospital personnel with QC and/or CAT. Forty received QC, 61 received CAT, and 6 received both products. The median age was 40 years (6-91 years), 29% were female, and the median injury severity score was 7 (1-25). QuikClot combat gauze was 89% effective. Minimal morbidity was associated with QC use. Combat application tourniquet was 98% effective. Median tourniquet time was 21 minutes (6-142 minutes), the median injury severity score was 9 (1-50), and mortality was 9.8%. Morbidities observed with tourniquet use included amputation, fasciotomy, rhabdomyolysis, and acute kidney injury. Risk of amputation was associated with higher injury severity (p = 0.04) but not with elderly age, obesity, or the presence of medical comorbidities. No amputations resulted solely from the use of tourniquets. CONCLUSIONS: QuikClot combat gauze and CAT are safe and effective adjuncts for hemorrhage control in the rural civilian trauma across a wide range of injury patterns. In a rural civilian population including women, children, and elderly patients with medical comorbidities, these devices are associated with minimal morbidity beyond that of the original injury. LEVEL OF EVIDENCE: Therapeutic study, level V.

Prehospital Use of Hemostatic Bandages and Tourniquets: Translation From Military Experience to Implementation in Civilian Trauma Care.

BACKGROUND: While the military use of tourniquets and hemostatic gauze is well established, few data exist regarding civilian emergency medical services (EMS) systems experience. METHODS: A retrospective review was performed of consecutive patients with prehospital tourniquet and hemostatic gauze application in a single ground and rotor-wing rural medical transport service. Standard EMS registry data were reviewed for each case. RESULTS: During the study period, which included 203,301 Gold Cross Ambulance and 8,987 Mayo One Transport records, 125 patients were treated with tourniquets and/or hemostatic gauze in the prehospital setting. Specifically, 77 tourniquets were used for 73 patients and 62 hemostatic dressings were applied to 52 patients. Seven patients required both interventions. Mechanisms of injury (MOIs) for tourniquet use were blunt trauma (50%), penetrating wounds (43%), and uncontrolled hemodialysis fistula bleeding (7%). Tourniquet placement was equitably distributed between upper and lower extremities, as well as proximal and distal locations. Mean tourniquet time was 27 minutes, with 98.7% success. Hemostatic bandage MOIs were blunt trauma (50%), penetrating wounds (35%), and other MOIs (15%). Hemostatic bandage application was head and neck (50%), extremities (36%), and torso (14%), with a 95% success rate. Training for both interventions was computer-based and hands-on, with maintained proficiency of %gt;95% after 2 years. CONCLUSION: Civilian prehospital use of tourniquets and hemostatic gauze is feasible and effective at achieving hemostasis. Online and practical training programs result in proficiency of skills, which can be maintained despite infrequent use.

Asthma and the immune response to MMR vaccine viruses in Somali immigrant children: a cross-sectional retrospective cohort study.

BACKGROUND: According to the 'hygiene hypothesis', an increase in microbial exposure in childhood leads to a T-helper cell 1 (Th1) predominant immune response and protection against asthma and atopic conditions. AIMS: To assess the prevalence of asthma and other atopic conditions in Somali immigrants and to determine the humoral immune response to the measles, mumps, and rubella (MMR) vaccine viruses in Somali immigrants with asthma. METHODS: A retrospective cohort study was conducted in Olmsted County, Minnesota. Study subjects were Somali immigrants who were born and lived in Africa during childhood and immigrated to the USA. The subjects had participated in a previous MMR vaccine study. Asthma was ascertained using predetermined asthma criteria after a thorough medical record review. An atopic condition was determined from physician-diagnosed ICD codes. Virus-specific IgG levels in response to the MMR vaccine viruses were determined using an enzyme immunoassay. RESULTS: Of the 62 eligible subjects, 33 (53%) were female and 29 (47%) were male; 10 (16%) had asthma and 22 (35%) had other atopic conditions. There was no difference in the rubella (p=0.150) and measles (p=0.715) virus-specific IgG levels between the subjects with and without asthma. Mumps virus-specific IgG antibody levels were lower in those with asthma than in those without asthma (mean±SE 2.08±0.28 vs. 3.06±0.14, p=0.005). CONCLUSIONS: Our study results may not support the hygiene hypothesis. In addition, the previously reported abnormal T-cell development in Caucasian children with atopy can be considered even in Somali immigrants.