Idarucizumab, but not procoagulant concentrates, fully restores dabigatran-altered platelet and fibrin components of hemostasis.

BACKGROUND: Comparative studies on the restoration of hemostasis with different reversal agents after dabigatran therapy have not been performed. We compared the efficacy and prothrombotic potential of the specific antidote idarucizumab with that of previously recommended non-specific procoagulant concentrates. STUDY DESIGN AND METHODS: We explored the in vitro effects of dabigatran (184 ng/mL) on fibrin and platelet-aggregate formation onto a damaged vessel under flow conditions (600 s-1 ). The reversal mechanisms and efficacy of idarucizumab (0.3-3 mg/mL) were compared with that of the non-specific procoagulant concentrates aPCC (25-75 U/Kg), PCC (70 U/Kg), or rFVIIa (120 µg/Kg). Generation of thrombin and prothrombin fragment (F1 + 2), and thromboelastometry parameters of clot formation were measured. RESULTS: Dabigatran caused pronounced reductions in fibrin (87%) and platelet interactions (36%) with damaged vessels (p < 0.01) and significantly impaired thrombin generation and thromboelastometric parameters (delayed dynamics and reduced firmness). Idarucizumab completely normalized rates of fibrin and platelet coverage to baseline values in flow studies; and reversed the alterations in thrombin generation, F1 + 2 and thromboelastometry parameters produced by dabigatran. In comparison, aPCC and PCC only partially compensated for the dabigatran-induced alterations in fibrin deposition, but were unable to fully restore them to baseline values. Reversal with aPCC or PCC improved the majority of alterations in coagulation-related tests, but tended to overcompensate thrombin generation kinetics and significantly increased F1 + 2 levels. CONCLUSION: Idarucizumab antagonizes alterations of direct and indirect biomarkers of hemostasis caused by dabigatran. In our studies, idarucizumab was clearly more efficacious than strategies with non-specific procoagulant concentrates and devoid of the excessive procoagulant tendency observed with the latter.

Un modelo nuevo, sencillo, económico y reutilizable para el aprendizaje y práctica de la canalización ecoguiada de vías centrales / A novel, simple, inexpensive and reusable model for learning and practice ultrasound-guided central vein cannulation

INTRODUCCIÓN: El acceso venoso central es una técnica esencial en la práctica de la medicina de urgencias y emergencias, y la utilidad de la ecografía de urgencia para guiar estos procedimientos ha sido ampliamente demostrada. Hemos desarrollado un modelo de tejido para la práctica y desarrollo de competencias en el acceso vascular por ecografía. MATERIAL Y MÉTODOS: El modelo de tejido consiste en una pieza de fiambre cocido, al cual se le realizan unos túneles (imitando vasos sanguíneos), en cuyos extremos se conectan conectores de riego de 13/16 mm, una llave de tres vías y una bolsa de suero intravenoso (por ejemplo, Ringer lactato o suero salino), al que se puede añadir un colorante. RESULTADOS: La imagen de ultrasonidos del túnel lleno de líquido simula un vaso sanguíneo. Es posible realizar la punción ecoguiada del túnel múltiples veces (> 10 veces) y aun así, por el sistema de gotero continuo conectado, mantener el «vaso» lleno de fluido y la integridad funcional. CONCLUSIONES: Presentamos una alternativa barata y tiempo-efectiva utilizando un modelo de simulación de fiambre cocido de cerdo o de York, y elementos fácilmente conseguibles. Creemos que el modelo de jamón de York se suma a la gama de modelos que se pueden utilizar para practicar el acceso vascular ecoguiado y, además, realizar este de forma repetida. Los componentes necesarios para la fabricación de este modelo son asequibles y están fácilmente disponibles

INTRODUCTION: Central venous access is an essential technique in emergency medicine and the utility of emergency ultrasound to guide this procedure has been widely demonstrated. We have developed a tissue model for training and development of skills the vascular access by echography. MATERIAL AND METHODS: The tissue model consists of a block of ham into which tunnels are carved (to imitate blood vessels). At the end of these tunnels, 13/16 mm irrigation connectors are attached, as well as three-way stopcocks and an intravenous crystalloid bag (i. e. : lactated Ringer's solution or normal saline) to which colorant may be added. RESULTS: The ultrasound image of the tunnel full of liquid simulates a blood vessel. It is possible to carry out ultrasound-guided punctures of the tunnel multiple times (> 10 times), keeping the vessel full of fluid and maintain the functional integrity due to the continuous drip system. CONCLUSIONS: We present a cheap and time-effective alternative for ultrasound-guided central vein cannulation using a block of ham and easily available components. The ham model can be added to the existing models used for ultrasound-guided techniques for vascular access, and can be used multiple times

Reversal of apixaban induced alterations in hemostasis by different coagulation factor concentrates: significance of studies in vitro with circulating human blood.

Apixaban is a new oral anticoagulant with a specific inhibitory action on FXa. No information is available on the reversal of the antihemostatic action of apixaban in experimental or clinical settings. We have evaluated the effectiveness of different factor concentrates at reversing modifications of hemostatic mechanisms induced by moderately elevated concentrations of apixaban (200 ng/ml) added in vitro to blood from healthy donors (n = 10). Effects on thrombin generation (TG) and thromboelastometry (TEM) parameters were assessed. Modifications in platelet adhesive, aggregating and procoagulant activities were evaluated in studies with blood circulating through damaged vascular surfaces, at a shear rate of 600 s(-1). The potential of prothrombin complex concentrates (PCCs; 50 IU/kg), activated prothrombin complex concentrates (aPCCs; 75 IU/kg), or activated recombinant factor VII (rFVIIa; 270 µg/kg), at reversing the antihemostatic actions of apixaban, were investigated. Apixaban interfered with TG kinetics. Delayed lag phase, prolonged time to peak and reduced peak values, were improved by the different concentrates, though modifications in TG patterns were diversely affected depending on the activating reagents. Apixaban significantly prolonged clotting times (CTs) in TEM studies. Prolongations in CTs were corrected by the different concentrates with variable efficacies (rFVIIa≥aPCC>PCC). Apixaban significantly reduced fibrin and platelet interactions with damaged vascular surfaces in perfusion studies (p<0.05 and p<0.01, respectively). Impairments in fibrin formation were normalized by the different concentrates. Only rFVIIa significantly restored levels of platelet deposition. Alterations in hemostasis induced by apixaban were variably compensated by the different factor concentrates investigated. However, effects of these concentrates were not homogeneous in all the tests, with PCCs showing more efficacy in TG, and rFVIIa being more effective on TEM and perfusion studies. Our results indicate that rFVIIa, PCCs and aPCCs have the potential to restore platelet and fibrin components of the hemostasis previously altered by apixaban.

Fractura de Pelvis. Una fractura compleja / Fracture of the Pelvis. A complex fracture

Se presenta el caso de un paciente joven con fractura de pelvis por accidente de tráfico. La fractura se presentó con una clínica abdominal y ECO FAST positivo con respuesta transitoria a la fluidoterapia. La biomecánica del accidente permitió sospechar la existencia de lesiones no observables con la proyección radiológica básica. El estudio de imagen diferido en 3D reveló la existencia de lesiones no visibles en la radiografía inicial, pero sospechadas por los antecedentes traumáticos. El presente caso nos permite repasar la sistemática de actuación ante un paciente politraumatizado (A-B-C-D-E), así como destacar la importancia que las fracturas de pelvis pueden tener en estos pacientes, ya que son causa de shock por pérdida de sangre masiva a nivel interno. Los pacientes con sospecha de fractura pélvica deben ser movilizados en bloque, manteniendo la alineación del eje cabeza-cuello-tronco, y una vez comprobada la estabilidad se debe proceder a la inmovilización de la pelvis, bien mediante un fajado pélvico o bien mediante dispositivos específicos para ello (AU)

We present a case of a young patient with a fractured pelvis due to a traffic accident. The patient had a positive FAST scan and transient response to fluid therapy. Due the biomechanics of the accident we suspected the existence of lesions that could not be observed with basic X-ray procedures. A 3-D image study revealed the lesions that were not visible by X-ray but suspected due to the nature of the trauma. This case enables us to review the A-B-C-D-E approach to the assessment of a polytraumatised patient and to emphasis the importance that a fractured pelvis could have for these patients as it is a cause of shock due to massive internal haemorrhage. Patients with a suspected fracture of the pelvis should be moved in block, maintaining the head-neck-trunk in line and once stabilised the pelvis should then be immobilised using a pelvic binder or other specific devices (AU)

Manejo inicial del paciente agitado / Management of the agitated patient in the emergency department

Los pacientes agitados son una situación clínica a la que con relativa frecuencia se enfrentarlos médicos en su práctica clínica. En la primera valoración, además de tomarlas oportunas medidas de seguridad, debemos de hacer un diagnóstico de presunción basado en el origen de la agitación (causa orgánica, trastorno mental subyacente o manifestación de una ansiedad extrema). Ello facilitará una posible resolución mediante un abordaje verbal o por el contrario se procederá a la contención mecánica. En caso de que se tome esta última decisión, se debe planificar con antelación y realizarla con al menos 5 personas. Dicha maniobra suele ser el paso previo a la contención con sedación farmacológica con benzodiacepinas, neurolépticos o una pauta combinada de ambos. Es necesario tener en cuenta el riesgo que suponen estos pacientes para su entorno familiar, el personal que lo atiende o incluso su propia vida, por lo que son candidatos a ingresar en unidades de psiquiatría de forma voluntaria o involuntaria. Si optamos por esta última, debe realizarse al amparo de la Ley, así como las medidas de contención y sedación adecuadas. Todas estas maniobras tienen que estar reflejadas con nuestro informe para el psiquiatra de guardia, que es quien realiza el ingreso (AU)

Agitated patients must be managed fairly often in routine emergency department practice. After safety measures are taken during initial assessment, a tentative diagnosis based on the cause of agitation (physical condition, underlying mental disorder, or extreme anxiety) should be made. That diagnosis will facilitate possible resolution of the problem through dialog with the patient or through physical restraint. If restraint is chosen, the manner of proceeding should be planned and at least 5 persons should be involved. The restraining maneuver is usually followed by administration of benzodiazepines, neuroleptic agents, or a combination of both in order to assure sedation. It is important to remember that these patients pose a threat to their families, emergency room staff, and themselves; therefore, they are candidates for voluntary or involuntary admission to a psychiatric unit. If that is the course of action chosen, admission must comply with the law and adequate restraint and sedation should be prescribed. All such actions should be recorded in the emergency department’s report to the psychiatrist on duty, who will be the admitting physician (AU)

Normativa sobre formación y utilización de desfibriladores semiautomáticos por personal no sanitario en España / Analysis of legislation on the use of semiautomatic external defibrillators by bystanders and the training of non-health-care professionals in Spain

Objetivos: Existe información suficiente que avala la utilización de la desfibrilación externa semiautomática por personal no sanitario entrenado en pacientes mayores de un año de edad con parada cardiorrespiratoria extrahospitalaria secundaria a fibrilación ventricular o taquicardia ventricular sin pulso. Sin embargo, la regulación legislativa de su aplicación es muy variable. Se compara las normas legislativas de formación y aplicación de la DESA en las diferentes CCAA españolas. Método: Análisis estructurado de las legislaciones de las CCAA españolas. Resultados: En España no existe ninguna limitación legal de ámbito estatal para el uso de DESA por personal no sanitario, pero tampoco existe una legislación positiva que lo autorice. Trece comunidades han elaborado normas reguladoras sobre esta materia. Existen tres diferentes modelos de formación en desfibrilación automática (DEA), el público, el externo y el mixto. Todos los programas destacan la necesidad de exigir que la formación sea realizada por instructores y/o monitores reconocidos por el Consejo Europeo de Resucitación o la Asociación Americana del Corazón. Conclusiones: El desarrollo legislativo de la DEA en las diferentes comunidades autónomas es muy variable: existen normas sólo en 13 de ellas y los modelos son muy diversos AU)

Background and objective: Sufficient evidence supports the use of semiautomatic external defibrillators outside the hospital by bystanders who are not health-care professionals, in patients over 1 year of age who are in cardiac arrest secondary to ventricular fibrillation or pulse less ventricular tachycardia. Legislation pertinent to the use of these defibrillators by bystanders is highly varied, however. Our aim was to compare legislation related to the training of bystanders in the use of semiautomatic external defibrillators and their application in the different autonomous communities of Spain. Methods: Structured analysis of relevant legislation in the Spanish autonomous communities. Results: No legal limitations are placed on bystanders’ use of semiautomatic external defibrillators in Spain. However, there is also no legislation explicitly authorizing it. Thirteen communities have written relevant laws. Three ways of providing training were identified. In 1 model, training is organized by public institutions, in another external trainers are authorized to organize courses, and in a third mixed alternative the 2 previous models are combined. All programs emphasize the need for training to take place under instructors recognized by the European Resuscitation Council or the American Heart Association. Conclusions: Legislation on the use of automatic and semiautomatic defibrillators in the different Spanish autonomous communities is highly varied. Only 13 communities have passed regulations and the training models described are very different (AU)

Randomized crossover pharmacokinetic evaluation of subcutaneous versus intravenous granisetron in cancer patients treated with platinum-based chemotherapy.

BACKGROUND: 5-HT3-receptor antagonists are one of the mainstays of antiemetic treatment, and they are administered either i.v. or orally. Nevertheless, sometimes neither administration route is feasible, such as in patients unable to admit oral intake managed in an outpatient setting. Our objective was to evaluate the bioavailability of s.c. granisetron. PATIENTS AND METHODS: Patients receiving platinum-based chemotherapy were randomized to receive 3 mg of granisetron either s.c. or i.v. in a crossover manner during two cycles. Blood and urine samples were collected after each cycle. Pharmacokinetic parameters observed with each administration route were compared by analysis of variance. RESULTS: From May to November 2005, 31 patients were included and 25 were evaluable. Subcutaneous granisetron resulted in a 27% higher area under the concentration-time curve for 0-12 hours (AUC(0-12h)) and higher levels at 12 hours, with similar values for AUC(0-24h). The maximum concentration was lower with the s.c. than with the i.v. route and was observed 30 minutes following s.c. administration. CONCLUSION: Granisetron administered s.c. achieves complete bioavailability. This is the first study that shows that s.c. granisetron might be a valid alternative to i.v. delivery. Further trials to confirm clinical equivalence are warranted. This new route of administration might be especially relevant for outpatient management of emesis in cancer patients.

Palpitaciones como presentación de Taquicardia de QRS estrecho en Pediatría / Palpitation like debut of tachycardia of thin qrs in paediatrics

La taquicardia paroxística supraventricular (TPSV) es la disritmia sintomática más frecuente en lainfancia después de las extrasístoles. Se presenta en lactantes como insufi ciencia cardiaca, asociandocon frecuencia cardiopatías estructurales, y en niños mayores como palpitaciones, palidez y ansiedad.Presentamos el caso de un niño de 6 años, sin antecedentes de interés, que mientras estaba jugandopresentó un episodio de taquicardia regular de QRS estrecho a 250 latidos/minuto, compatible con eldiagnóstico de TPSV por reentrada auriculoventricular

The paroxysmal supraventricular tachycardia (PSVT) is the second symptomatic arrhythmia more frequentin infancy later extrasistols. It occurs in lactation like a hearth insuffi ciency, frequently associatedwith structural cardiopathy and in elder children like palpitations, paleness or anxiety. We show thecase of a 6 years old child without pathologic antecedents, who suffer an event of regular tachycardiadefi ned by thin QRS and a frequency of 250 bpm compatible with the diagnostic of PSVT by auriculoventricular reentry while he was playing (AU)