The Blog

Thanks for dropping by! We have curated an incredible collection of the best articles from the leading Emergency Medicine, Tactical Medicine, Prehospitial Medicine, Austere & Remote Medicine authors, as well as Survival Medicine gurus and many others!

We hope you find something of interested to you, please use the search bar on top to narrow down what you are looking for.

As always, all credit is given to the original author and origin publication.

Blogs

Journal Jam 18 The Evidence for TXA – Should Tranexamic Acid Be Routine Therapy in the Bleeding Patient?

Anton Helman | Jun 29, 21

With the help of a special guest, EBM guru Dr. Ken Milne of the The SGEM, Anton and Justin look at all the various potential indications for TXA and review the available evidence. Should we be using TXA for epistaxis, postpartum hemorrhage, hyphema or hemoptysis? Is it a miracle drug that stops all bleeding? Or has it been drastically overhyped? Was CRASH-2 enough to be definitive, or does the classic EBM mantra of  "we need more studies" remain true?...

The post Journal Jam 18 The Evidence for TXA – Should Tranexamic Acid Be Routine Therapy in the Bleeding Patient? appeared first on Emergency Medicine Cases.

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Marco Torres | Mar 06, 21
REBEL Cast Ep97: The NoPAC Trial – TXA for Epistaxis?

Background: Epistaxis is a common Emergency Department (ED) complaint with over 450,000 visits per year and a lifetime incidence of 60% (Gifford 2008, Pallin 2005). Standard anterior epistaxis treatment consists of holding pressure, use of local vasoconstrictors, topical application of silver nitrate and placement of an anterior nasal pack. ED patients with epistaxis often fail conservative management and end up with anterior nasal packs which are uncomfortable. This is even more common in the group of patients who are taking antiplatelet agents or anticoagulants. In recent years, tranexamic acid (TXA) has been added to many physicians’ armamentarium based on small studies (REBEL EM). While topical TXA has minimal safety concerns and is relatively inexpensive, higher quality studies are needed to further evaluate this treatment approach.

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Anton Helman | Feb 09, 21
Ep 152 The 7 Ts of Massive Hemorrhage Protocols

Dr. Jeannie Callum, Dr. Andrew Petrosoniak and Dr. Barbara Haas join Anton in answering the questions: How do you decide when to activate the MHP? How do you know when it is safe to terminate the MHP? What lab tests need to be done, how often, and how should the results be shared with the clinical team? Once the dust settles, what do we need to tell the patient and/or their family about the consequences of being massively transfused? What should be the lab resuscitation targets? Why is serum calcium important to draw in the ED for the patient who is exsanguinating? How do we mitigate the risk of hypothermia? What can hospitals do to mitigate blood wastage? If someone is on anti-platelets or anticoagulants what is the best strategy to ensure the docs in the ED know what to give and how much? Until the results of lab testing come back and hemorrhage pace is slowed, what ratio of plasma to RBCs should we target? What's better, 1:1:1 or 2:1:1? Should we ever consider using Recombinant Factor 7a? If the fibrinogen is low, what is the optimal product and threshold for replacement? When and how much TXA? Anyone you wouldn’t give it to? and many more...

The post Ep 152 The 7 Ts of Massive Hemorrhage Protocols appeared first on Emergency Medicine Cases.

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Marco Torres | Nov 26, 20
IM Administration of Tranexamic Acid

Background: We have covered tranexamic acid (TXA) on this blog in several posts. Its use has been studied for everything that bleeds from abnormal uterine bleeding to GI hemorrhage and from multisystem trauma to intracranial hemorrhage. While over the past few years it has been touted as the wonderdrug for bleeding, newer research is beginning to challenge that thought (CRASH-3 trial, HALT-IT trial, etc.).

The CRASH-2 trial showed that early administration of TXA (within 3 hours) to trauma patients improved all-cause mortality. However, obtaining rapid IV access in low resource, rural, or combat settings can be challenging. Only recently has research been conducted about intramuscular administration of TXA. Actually…we should really say that there has been a resurgence of interest in IM TXA. There were a couple studies published about its pharmacokinetics and pharmacodynamics in the 1970s and 80s, followed by radio silence on the subject.1,2 Curiosity about the drug has picked back up over the past decade as its cost dropped and access to TXA increased exponentially. In fact, finding alternative routes of TXA administration in postpartum hemorrhage is a WHO priority.3

Today, we will review a recent article that explored the pharmacokinetics of intramuscular TXA in bleeding trauma patients.

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Anton Helman | Nov 24, 20
Ep 149 Liver Emergencies: Thrombosis and Bleeding, Portal Vein Thrombosis, SBP, Paracentesis Tips and Tricks

In this part 2 of our 2 part series on Liver Emergencies we clear up the confusing balance between thrombosis and bleeding in liver patients, the elusive diagnosis of portal vein thrombosis, spontaneous bacterial peritonitis diagnosis and treatment and some tips and tricks on paracentesis with Walter Himmel and Brian Steinhart....

The post Ep 149 Liver Emergencies: Thrombosis and Bleeding, Portal Vein Thrombosis, SBP, Paracentesis Tips and Tricks appeared first on Emergency Medicine Cases.

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Marco Torres | Oct 24, 20
Should we Rubber STAAMP Prehospital TXA?

Background: It almost seems that when it comes to the use of the antifibrinolytic agent tranexamic acid (TXA) in trauma, one argument has just been completed and another one comes up right behind it.

Let’s take a step back. Most agree that the evidence clearly supports the role of the early in-hospital administration of TXA in major trauma (in conjunction with balanced blood product transfusion practices). Given the benefit of in-hospital use, and the evidence supporting most benefit with earlier use, it seemed to make intuitive sense to bring this out into the prehospital setting closer to the point-of-injury – many agencies have done just that. However, this particular area of use did not have any associated high-quality evidence.

Led by a team out of the University of Pittsburgh (the same group that brought us the PAMPer trial in 2018), Guyette et al just released the Study of Tranexamic Acid During Air Medical and Ground Prehospital Transport (STAAMP) trial, published in JAMA Surgery.

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Marco Torres | Oct 05, 20
Out-Of-Hospital TXA for TBI

Background: The CRASH-2 trial, published in 2010, showed a survival benefit for patients with traumatic hemorrhage who received TXA compared to placebo.  TXA has become standard practice in many settings as a result of this data. However, patients with significant head injury were excluded in this study and, it was unclear of the effect of TXA in this group. In 2019, CRASH-3 examined the use of TXA in traumatic brain injury (TBI) and found the overall effect size of TXA on ICH was not statistically significant compared to placebo.  Subgroup analysis demonstrated that certain patients (<3hrs, GCS 9 – 15, and ICH on baseline CT) showed benefit with TXA. However, this data was hypothesis generating only: not the primary outcome of the trial and with wide confidence intervals.  Further data is clearly needed to elucidate the role of TXA in those with TBI.

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