Use of Atomized Intranasal Tranexamic Acid as an Adjunctive Therapy in Difficult-to-Treat Epistaxis.

There is a growing body of literature on the safe, effective use of tranexamic acid (TXA) for hemostasis in a variety of clinical settings. We present a case series of three patients with difficult-to-treat epistaxis where standard treatment methods were not effective. Using atomized intranasal TXA (ATXA) as part of a stepwise treatment approach, we were able to achieve hemostasis and manage all three cases independently, and we did so without major complications in our emergency department (ED). Given recent literature showing the underuse of TXA in combat casualties, ATXA, if formulated and delivered properly, may be of benefit for epistaxis and other significant hemorrhage cases. Further work must be done to elucidate the mechanism of action, specific dose, delivery method, use indications, and safety profile of ATXA.

Photoletter to the editor: Diffuse cocaine-related purpura.

Diffuse purpura is an uncommon skin manifestation found in platelet and coagulation disorders, meningococcemia, vasculitides and cocaine use. Reports of cocaine-related purpura predominantly involve adulteration with the anti-helminthic, levamisole. Levamisole enhances the effects of cocaine and is known to cause vasculitis. Recently, the CDC also released an advisory of oxymorphone being used intravenously causing thrombogenic thrombocytopenic purpura (TTP). We report the case of a patient with diffuse purpura ultimately diagnosed with cocaine-related thrombogenic vasculopathy. In the current environment of adulterated cocaine usage and increased prescription narcotic abuse, it is crucial to investigate substance abuse as a cause of diffuse purpura.

Expect the unexpected: two cases of penetrating head and neck trauma from Operation Iraqi Freedom.

The protocol for treating penetrating head and neck trauma in a war zone differs from the standard protocol. Rather than first securing an airway, as is standard in civilian trauma cases, the primary emphasis is on assessing and controlling hemorrhage because it is the leading cause of morbidity and mortality in a battlefield setting. Once that has been addressed, we shift to standard advanced-trauma life-support protocols. We describe two cases we encountered at our combined medical clinic in Western Baghdad--one involving a 4-year old Iraqi child with an ammunition round lodged in her neck and one involving a 38-year-old female U.S. soldier with a round lodged in her right superolateral orbit. Both cases were transferred to combat support hospitals for further treatment after our initial assessment and treatment, and both had successful outcomes.

The use of multiple intraosseous catheters in combat casualty resuscitation.

During the current military engagements in Iraq and Afghanistan, establishing intravenous (IV) access for resuscitation of critically injured casualties remains a persistent challenge. Intraosseous (IO) access has emerged as a viable alternative in resuscitation. In this case report, a 19 year-old male soldier was severely wounded by a roadside bomb in Iraq. Given the heavy initial blood loss, anatomic location of the injuries and gross wound contamination, peripheral IV access could not be established. Instead, multiple IO catheters were used to initiate fluid resuscitation prior to transfer to a combat support hospital. To our knowledge, this is the first report of such extensive usage of IO catheters. Multiple IO catheters can be placed rapidly and safely and may help solve the challenge of establishing vascular access for resuscitation of critically injured casualties.