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Background and Objective: Bleeding control is extremely important in any surgical procedure, especially in neurological surgery. Hemodilution with colloid and crystalloid may predispose to functional impairment of fibrinogen, which replacement may be beneficial. We evaluated the safety of fibrinogen concentrate administration in patients who underwent a neurosurgical procedure. Method: We reviewed the medical charts of a series of consecutive patients who received prophylactic fibrinogen concentrate and underwent a neurosurgical procedure for different pathologies in our institution from July 2009 to July 2010. Adverse effects, red blood cells and platelet transfusions were carefully recorded in all cases. Results: Twelve patients were included in our study. There were seven (58%) men and five (42%) women, with a median age of 37 years. All patients had a normal baseline laboratory tests. There was no case of allergic reactions or any adverse events related to fibrinogen administration. None of them required red blood cells or platelet transfusions after surgery, and there were no thrombotic events during 30 days of follow-up. Conclusion: The prophylactic use of fibrinogen concentrate appears to be safe in neurosurgery and may reduce the need of blood derivatives transfusion. Additional prospective studies should be performed to assess the efficacy of this strategy.

Introducción: la hemofilia A y B severa son condiciones que predisponen al sangrado espon-táneo. Una de las complicaciones de la terapia con concentrados de factores de coagulación es el desarrollo de anticuerpos o inhibidores contra los factores VIII o IX. El tratamiento en casos de inhibidores de título alto, para el control de la hemorragia, es la administración de agentes puente como el complejo protrombínico activado y Factor VII recombinante activa-do. La respuesta a cada uno de ellos no es predecible, en algunos casos puede ser necesario el uso de la terapia secuencial cuando esta estrategia falla. Objetivo: reportar cinco casos de hemofilia A severa e inhibidores de título alto con sangrado severo, sin respuesta clínica con monoterapia y que recibieron terapia secuencial. Métodos: estudio multicéntrico, descriptivo, observacional. Las variables cualitativas se pre-sentan con frecuencias absolutas y relativas, y las cuantitativas se resumen con medidas de tendencia central. Resultados: cuatro pacientes evaluados que aportaron cinco eventos, la mediana de edad 20 años; mediana de días de monoterapia 10; 8,6 días de terapia secuencial, tiempo a resolver el sangrado cuatro días. Ausencia de complicaciones trombóticas. Conclusiones: la terapia secuencial es una opción para aquellos pacientes que no responden a la monoterapia y requieren control hemostático. En los cinco casos reportados, la terapia secuencial logró controlar el sangrado sin complicaciones.

Background. In spite of the achievements of modern gastroenterology the number of patients with ulcerative gastroduodenal bleeding do not tend to decrease. Lethality is still rather high – from 10 to 15%, which reaches 20-45% during the recurrence of bleeding. Endoscopic hemostasis was effective in 96-98% of the patients only. Indications for surgical treatment when endoscopic hemostasis has been performed are still the subject of discussion. Purpose. To analyze data on the results of emergency care and treatment of the patients with gastroduodenal ulcer bleeding in the city specialized bleeding center to optimize therapeutic and diagnostic tactics. Material and methods. The analysis of data on the results of treatment of 981 patients with ulcerative gastroduodenal bleeding. Results. In the clinic, an algorithm for therapeutic and diagnostic measures for effective treatment of the patients has been developed, based on the possibility of carrying out 24-hour endoscopy study, which makes it possible to identify the source of bleeding in the shortest possible time, to determine its character, to assess the stability of hemostasis, and simultaneously perform endoscopic hemostasis (temporary or final). Further therapeutic tactics is based on the complex prediction of gastroduodenal ulcer bleeding recurrence, the automated assessment of the severity of the patient's condition with the definition of the degree of operational risk and the rational replenishment of the circulating blood volume based on a computerized assessment of the transfusion requirement. Conclusions. The application of modern endoscopic methods of bleeding control enabled to reach the final hemostasis in 99.3% of patients with gastroduodenal ulcer bleeding which significantly reduced the number of emergency operations.

Background : Hemorrhage and the complications thereof have traditionally been managed surgically but over the last two decades endovascular techniques have been increasingly used. These include coiling, liquid and particle embolization among others. These minimally invasive techniques now available locally are safe and cost effective. They are however yet to be fully adopted in acute emergency settings. Methods : Fifty two patients with acute bleeding from known causes and whose first surgical intervention was not successful in controlling the bleeding were referred for emergent endovascular embolization. Results : The causes of the bleeding included post traumatic bleeds from intra-abdominal organ injury, iatrogenic pseudoaneurysms, massive hemoptysis among others. There was 100% technical and clinical success rate in hemorrhage control. None of the patients required a repeat endovascular procedure for bleeding control and no major complications were reported. Conclusion : Endovascular embolization was successful in controlling bleeding in all of the patients. It is effective, safe and available as a first line choice. It should be considered in all patients presenting with severe hemorrhage from known causes in the initial presentation. Key words: Embolization, Interventional radiology, Vascular

There has been a rise in mass casualty events over the past decade. The Stop the Bleed initiative aims to increase survivorship in these events by teaching the basics of bleeding control. This educational intervention was conducted to instruct nursing students on the basics of bleeding control and emergency preparedness. The ultimate result of this project is that 143 future nurses that now have the skills to stop life-threatening bleeding in an emergency situation.

Despite over a half-century of recognizing fibrinolytic abnormalities after trauma, we remain in our infancy in understanding the underlying mechanisms causing these changes, resulting in ineffective treatment strategies. With the increased utilization of viscoelastic hemostatic assays (VHAs) to measure fibrinolysis in trauma, more questions than answers are emerging. Although it seems certain that low fibrinolytic activity measured by VHA is common after injury and associated with increased mortality, we now recognize subphenotypes within this population and that specific cohorts arise depending on the specific time from injury when samples are collected. Future studies should focus on these subtleties and distinctions, as hypofibrinolysis, acute shutdown, and persistent shutdown appear to represent distinct, unique clinical phenotypes, with different pathophysiology, and warranting different treatment strategies.

Introduction Road Traffic Injuries (RTI) are one of the toughest public health challenges confronting India. An estimated 40% of RTI deaths are due to uncontrolled bleeding. Stopping the bleeding in the first few minutes is crucial for meaningful survival considering the delays between the RTI and definitive trauma care. Our objective was to develop and implement a lay first responder Active Bleeding Control (ABC) program to help RTI victims along two high risk corridors using simulation methodology. Methods ABC is a multi-partner collaboration pilot program with government and non-governmental agencies. Therefore, using EMS and Police geolocation data, two corridors of 50 kms of highway with high risk of RTI were identified in Medchal district (population 2.5 million) near Hyderabad city, India. In depth interviews with 22 potential lay first responders were conducted in 2019 to understand the barriers for helping RTI victims. Simulation training modules were developed using a step-by-step scenario script and a 90-min curriculum including a video. A low cost ‘stop the bleed kit' was developed and distributed among volunteers. Data collection to capture use cases, barriers and facilitators to program success is ongoing. Results All 22 respondents reported having witnessed many life-threatening RTI in the area, and had no previous knowledge, training or skills in bleeding control. 1005 ABC volunteers have now been simulation trained to stop the bleed. Of these, 162 have self-reported helping RTI victims on the selected highway corridors. The ABC pilot program shows that by training lay first responders to assess and arrest bleeding, passive RTI "by-standers" can be converted into active "try-standers". Conclusion The ABC program has the potential to create a much-needed community of trained citizens to help save lives from RTI in India.

With the vast increase in endovascular procedures and the use of percutaneous vascular closure devices, there is an increasing risk of closure failure and bleeding demanding open surgical repair that might be surgically challenging. We describe two ways, using a modern hybrid technique and tools (endovascular and open surgery), of controlling bleeding with minimal blood loss, which might facilitate the surgery.

The balloon-assisted enteroscope has been regarded as the standard device for direct visualization of deep small bowels and allows for the diagnosis and treatment of small bowel disease. At the beginning, its application was focused on the diagnosis of obscure gastrointestinal bleeding, inflammatory bowel disease, and small bowel tumor. However, the indications are being expanded to various therapeutic procedures, not only confined to bleeding control. With the expansion of the indications, the need to perform enteroscopy effectively and safely is increasing. Recent studies have been focused on the diagnostic yield, therapeutic yield, and long-term outcomes of the device. However, with the increasing number of procedures, procedural guidelines and quality indicators are also needed.

The initial assessment and care determine the quality of the secondary surgical treatment of complex hand wounds. The caregiver providing this initial care plays a critical role. The analysis of the management of these traumas in exceptional situations enables the key stages of the initial treatment to be identified: bleeding control, infection prevention and an accurate assessment of the injury. These measures thereby help to optimise the patient's transfer towards a specialised unit.

Ein Uberrolltrauma ist fur das Unfallopfer meist mit multiplen Verletzungen verbunden. Eine pragmatische Blutungskontrolle ist essenziell. Die typischen Druck- und Scherkrafte konnen an der Grenzflache von Subkutis und Faszie eine Minderperfusion des Gewebes und auch die Entstehung von grosen flussigkeitsgefullten Hohlraumen verursachen, das Vollbild einer sogenannten Morel-Lavallee-Lasion. In den Hohlraumen ist die Bildung von Infektionen und Nekrosen moglich, die den Krankheitsverlauf nachhaltig negativ beeinflussen konnen. Daher sollte zur Vermeidung lokaler und auch systemischer Komplikationen, wie einer Sepsis, eine adaquate Entlastung mit entsprechender Befundsanierung herbeigefuhrt werden.

A variety of complications in endoscopic third ventriculostomy have been reported, including neurovascular injury, hemodynamic alterations, endocrinologic abnormalities, electrolyte imbalances, cerebrospinal fluid leakage, fever and infection. Even though most complications are transient, the overall rate of permanent morbidity is 2.38% and the overall mortality rate is 0.28%. To avoid these serious complications, we should keep in mind potential complications and how to prevent them. Proper decisions with regard to surgical indication, choice of endoscopic entry and trajectory, careful endoscopic procedures with anatomic orientation, bleeding control and tight closure are emphasized for the prevention of complications.

Over the last decade the age of trauma patients and injury mortality has increased. At the same time, many centers have implemented multiple interventions focused on improved hemorrhage control, effectively resulting in a bleeding control bundle of care. The objective of our study was to analyze the temporal distribution of trauma-related deaths, the factors that characterize that distribution and how those factors have changed over time at our urban level 1 trauma center.Records at an urban Level 1 trauma center were reviewed. Two time periods (2005-2006 and 2012-2013) were included in the analysis. Mortality rates were directly adjusted for age, gender and mechanism of injury. The Mann-Whitney and chi square tests were used to compare variables between periods, with significance set at 0.05.7080 patients (498 deaths) were examined in 2005-2006, while 8767 patients (531 deaths) were reviewed in 2012-2013. The median age increased 6 years, with a similar increase in those who died. In patients that died, no differences by gender, race or ethnicity were observed. Fall-related deaths are now the leading cause of death. Traumatic brain injury (TBI) and hemorrhage accounted for 91% of all deaths. TBI (61%) and multiple organ failure or sepsis (6.2%) deaths were unchanged, while deaths associated with hemorrhage decreased from 36% to 25% (p0.01). Across time periods, 26% of all deaths occurred within one hour of hospital arrival, while 59% occurred within 24h. Unadjusted mortality dropped from 7.0% to 6.1 (p=0.01) and in-hospital mortality dropped from 6.0% to 5.0% (p0.01). Adjusted mortality dropped 24% from 7.6% (95% CI: 6.9-8.2) to 5.8% (95% CI: 5.3-6.3) and in-hospital mortality decreased 30% from 6.6% (95% CI: 6.0-7.2) to 4.7 (95% CI: 4.2-5.1).Over the same time frame of this study, increases in trauma death across the globe have been reported. This single-site study demonstrated a significant reduction in mortality, attributable to decreased hemorrhagic death. It is possible that efforts focused on hemorrhage control interventions (a bleeding control bundle) resulted in this reduction. These changing factors provide guidance on future prevention and intervention efforts.

OBJECTIVE: Tranexamic acid (TXA) and the hemostatic agent Floseal® have already been used to minimize bleeding during total knee arthroplasty (TKA). METHODS: We conducted a prospective, randomized study of 90 patients with indications for TKA. Following inclusion, the participants were randomly allocated in blocks to the following 3 groups: control, Floseal® and TXA. Bleeding parameters, including decreases in hemoglobin (Hb), drain output, number of blood transfusions and complications, were assessed. ClinicalTrials.gov: NCT02152917. RESULTS: The mean decrease in Hb was highest in the control group (4.81±1.09 g/dL), followed by the Floseal® (3.5±1.03 g/dL) and TXA (3.03±1.2 g/dL) groups. The Floseal® and TXA groups did not differ, and both performed better than the control group. The mean total drain output was 901.3±695.7 mL in the control group, 546.5±543.5 mL in the TXA group and 331.2±278.7 mL in the Floseal® group. Both TXA and Floseal® had significantly less output than the control group, and Floseal® had significantly less output than TXA. The number of blood transfusions was very small in all 3 groups. CONCLUSION: The use of TXA or Floseal® was associated with less blood loss than that of the control group among patients undergoing primary TKA, as measured both directly (intraoperative bleeding + drainage) and on the basis of a decrease in Hb, without differences in the rate of complications. TXA and Floseal® showed similar decreases in Hb and total measured blood loss, but the drain output was smaller in the Floseal® group.

The pectus bar removal procedure is often considered a simple, straightforward surgery with a low incidence of complications. However, life-threatening bleeding complications have been reported requiring major measures for hemostatic control. Our objective is to share a simple maneuver that our group has systematically included in the bar removal procedure to facilitate bleeding control in case hemorrhage occurs.

Uncontrolled haemorrhage shock is the highest treatment priority for military trauma surgeons. Injuries to the torso area remain the greatest treatment challenge, since external dressings and compression cannot be used here. Bleeding control strategies may thus offer more effective haemostatic management in these cases. Chitosan, a linear polysaccharide derived from chitin, has been considered as an ideal material for bleeding arrest. This study evaluated the potential of chitosan-based dressings relative to commercial gauze to minimise femoral artery haemorrhage in a swine model. Stable haemostasis was achieved in animals treated with chitosan fibre (CF) or chitosan sponge (CS), resulting in stabilisation of mean arterial pressure and a substantially higher survival rate (100% vs. 0% for gauze). Pigs receiving treatment with CF or CS dressings achieved haemostasis within 3.25 ± 1.26 or 2.67 ± 0.58 min, respectively, significantly more rapidly than with commercial gauze (>100 min). Moreover, the survival of animals treated with chitosan-based dressings was dramatically prolonged (>180 min) relative to controls (60.92 ± 0.69 min). In summary, chitosan-based dressings may be suitable first-line treatments for uncontrolled haemorrhage on the battlefield, and require further investigation into their use as alternatives to traditional dressings in prehospital emergency care.

The health burden of injury on our society is substantial, and injury remains the leading cause of death in the United States, accounting for 59% of deaths up to age 45. The majority of injury mortality occurs before hospital arrival, with 62% of civilian and 87% of military traumatic deaths reported to occur prehospital. The concept of analyzing mortality after injury along a chronologic access was introduced in Dr. Trunkey’s seminal work describing the trimodal distribution of trauma deaths in immediate, early, and late timeframes after injury. “Immediate” deaths after trauma occur within less than 1 hour and are best addressed through trauma system development that includes prevention and safety interventions. “Early” deaths are most commonly attributed to massive bleeding and severe central nervous system injuries; the interval between injury and bleeding control has been identified as the key factor in survival for this group of severely injured patients. Trauma system development and injury care has focused intensely on early resuscitation and control of bleeding, largely through increased emphasis on prehospital care and rapid transport to designated trauma centers. The “late” timeframe of death after injury corresponds to patients who die days or weeks after injury usually due to infection, multiple organ failure, or devastating brain injury. About one-fourth of trauma deaths may be potentially preventable. Interventions dedicated to advanced bleeding control and hemostatic resuscitation in the field early after injury in tactical and austere environments have the greatest potential to improve survival after injury.

The Bernard-Soulier syndrome also known as hemorrhagioparous thrombocytic dystrophy, is a rare autosomal recessive bleeding disorder. Macrothrombocytopenia and increased bleeding time are the two main features of this syndrome. There is a reduced adherence of giant platelets to the subendothelium due to a deficiency of glycoprotein GPIb-V-IX complex. Routine dental extraction in a patient with a bleeding disorder can lead to life-threatening complications and there are very few specific protocols for the same. Here, we present a case report describing haemostasis management during dental extraction in a 7-year-old female child, suffering from this syndrome. It was observed that the preoperative and postoperative human leucocyte antigen-matched platelet transfusion, systemic intraoperative tranexamic acid and minimally traumatic procedure improved bleeding control and management.

ObjectiveThe purpose of this case series is to describe the application of a vascular closure button (VCB) for the repair of haemodialysis access bleeding. The VCB’s main function is not to assist in bleeding control, but instead to provide easy access for removal of tightly placed sutures in the repair.MethodsA retrospective review of patients undergoing ED repair of persistent bleeding from puncture sites in haemodialysis access conduits (HACs) using a VCB was conducted. Study patients were collected from ED visits to Our Lady of Lourdes Medical Center in Camden, New Jersey, USA, between May 2013 and August 2017. Patients were followed until the time of definitive repair of the underlying pathology or until the end of the study period.ResultsSeventeen VCBs were used to control persistent bleeding from HACs in the ED. Sixteen bleeds were the result of recent haemodialysis punctures, while one was from a bleeding site ulcer. All repairs were successful at controlling the bleeding with preserved HAC function in the ED and no delayed thrombosis. Follow-up time ranged from 1 day to 778 days.ConclusionVascular control buttons provide an effective means to control HAC postdialysis bleeding and allow for ease of suture removal without disruption of a repair with no long-term complications.

Nurses can prepare the public to save lives following a mass casualty event.

Background As active shootings and mass casualty incidents have become more prevalent, courses designed to teach basic hemorrhage control to laypersons have proliferated. Participants currently undergo Stop the Bleed (StB) training currently use a synthetic limb mannequin. In a prior survey of 88 participants, there was overwhelming sentiment that the mannequin was limited by its inability to demonstrate cessation of bleeding when hemorrhage control techniques were applied. We hypothesized that simulated bleeding that can be controlled by StB techniques would improve the mannequin and increase confidence of trainees in achieving bleeding control. Methods The mannequin was redesigned to be a self-contained model mimicking bleeding, with fluid flowing from a reservoir into a latex tubing with a laceration mimicking an arterial wound. Fluid was pumped by a rubber bulb attached to the tubing and held in the instructor's hand. Twenty StB trainers conducted beta testing of the perfused mannequin. Forty participants underwent training with both old and new models and completed posttraining surveys. Results Beta-testers reported positive feedback regarding both realism of the perfused mannequin and participants' ability to obtain bleeding control using StB techniques. Participants who trialed the mannequin reported increased awareness of the rate of blood flow out of a wound, which in turn increased their sense of urgency to achieve hemostasis. Conclusions In an effort to address shortcomings noted by participants in the current StB mannequin, we developed a novel perfused bleeding mannequin, which responds appropriately to various hemorrhage cessation techniques and is both high fidelity and low cost.

BackgroundThe American College of Surgeons Bleeding Control Basic (BCon) course aimed at teaching hemorrhage control techniques in the USA had not yet been taught in Spain. The purpose of this study is to assess its implementation among students and healthcare employees in the Lozano Blesa University Hospital of Zaragoza, a middle-sized Spanish city.MethodsThe study was conducted in a University Hospital and at the University of Zaragoza, scheduling four free B-Con sessions from 2017 to 2018. Two groups were identified as forming the population: healthcare employees and medical students. An anonymous questionnaire was completed at the end of the course regarding content, applicability, usefulness, relevance, and satisfaction. Study variables were ranked from 0 to 10: poor (when graded from 0 to 3), fair (4 to 6) and good (7 to 10). Results were compared between the groups, expressed in percentages and χ2 tested to analyze significant differences if any.ResultsAmong the 83 individuals who completed the course, 46 were medical students and 37 healthcare employees; 61% women and 39% men; aged 21 years to 52 years. Attendees evaluated satisfaction with the highest grade (84%), followed by usefulness (73%), applicability (70%), and relevance (66%). There was no variable graded as poor. The comparison of perceptions between groups did not reveal statistical differences based on a 0.05 significance level.ConclusionWe concluded that the B-Con course was valued as good for relevance, usefulness, applicability, and satisfaction by the majority of the studied population.Level of evidenceLevel III.

RESUMO Convencionalmente, a associação de anestésicos locais com vasoconstritores é evitada em extremidades pelo risco de isquemia. Entretanto, estudos recentes sugerem haver segurança no uso de vasoconstritor em extremidades. Procuramos, assim, avaliar a efetividade e segurança do uso de vasoconstritores combinados com anestésicos locais no bloqueio de nervos digitais em comparação ao uso de anestésicos plenos, através de uma revisão sistemática com metanálise de ensaios clínicos randomizados. Pesquisamos, até maio de 2019, nas bases de dados MEDLINE, LILACS, SciELO, ScienceDirect, Scopus, ClinicalTrials.gov e literatura cinzenta, sem restrições de data ou idioma, os descritores: bloqueio digital, vasoconstritor e isquemia. Foram incluídos ensaios clínicos randomizados nos quais houve a utilização de anestésicos locais associados ou não a vasoconstritores em bloqueios digitais. Nas variáveis primárias foram analisadas a ocorrência de complicações isquêmicas e a duração da anestesia, e nas variáveis secundárias foram observadas necessidade de reaplicação anestésica, de controle de sangramento e latência. Dez estudos foram incluídos nesta revisão. Não foi observada a ocorrência de isquemia, independente do uso ou não de vasoconstritores. O uso de vasoconstritores na concentração de 1:100.000 ou menor esteve associado a maior duração da anestesia (P

Objective: Algan hemostatic agent (AHA) is a plant-based hemostatic agent produced in Turkey. Although, there is a great improvement in the hemostatic technologies, more effective hemostatic products are required to be produced. The aim of this study was to demonstrate the efficacy of AHA in a partial splenectomy model in rats. In addition, in this model, postoperative abdominal adhesion was evaluated. Materials and Methods: In this study 5-7 weeks old 64 rats were used. Rats were randomly divided into 8 groups, each consisting of eight rats (4 groups heparinized and 4 groups non-heparinized). Experimental splenectomy was performed and the gauze impregnated with saline was applied to the control group for the hemorrhage control, the gauze impregnated with liquid AHA, gel and powder form of AHA, was applied to the experimental groups. Results: The time to reach complete homeostasis was significantly shorter in all AHA groups compared to the control group. The powder and the gel forms of AHA stopped the bleeding in heparinized and non-heparinized groups in 1 second. The AHA fluid (sponge) form stopped the bleeding in the first application in the control group less than 10 seconds and the second time application was not necessary. The bleeding was able to be controlled in the heparinized control group (saline impregnated sponge) by 55 seconds and in the non-heparinized control group by 38 seconds. Conclusion: This study showed that AHA is a highly effective hemostatic agent, which would be beneficial in controlling hemorrhage. © 2019, Marmara University. All rights reserved. This study was supported by the Algan Group Health Services (Algan Group Health Services Import and Export Industry and Trade Limited Company, Istanbul, Turkey). The company provided the study materials for the scientists, but had no role for the study design, data collection and analysis. The decision to publish and the preparation of the manuscript also belong to the authors.