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There are situations in the pre-hospital setting where gaining intravenous or intraosseous access is impossible or delayed. This can delay the administration of tranexamic acid to bleeding trauma patients, which may reduce its effectiveness. We sought to investigate whether some patients would benefit from early administration of tranexamic acid via the intramuscular route. Relevant observational and interventional studies were identified and summarised using a BestBET format. The current evidence supports clinicians considering intramuscular tranexamic acid in trauma patients at risk of haemorrhage when there may be significant delay in administration via intravenous or intraosseous routes.

IntroductionDespite mitigation efforts, exertional heat stroke (EHS) is known to occur in military personnel during training and operations. It has significant potential to cause preventable morbidity and mortality. International consensus from sports medicine organisations supports treating EHS with early rapid cooling by immersing the casualty in cold water. However, evidence remains sparse and the practice is not yet widespread in the UK.MethodsFollowing changes to enable on-site ice cold water immersion (ICWI) at the Royal Marines Commando Training Centre, Lympstone, UK, we prospectively gathered data on 35 patients treated with ICWI over a 3-year period. These data included the incidence of adverse events (e.g. death, cardiac arrest or critical care admission) as the primary outcome. Basic anthropometric data, cooling rates achieved and biochemical and haematological test results on days 0–5 were also gathered and analysed.ResultsDespite being a cohort of patients in whom we might expect significant morbidity and mortality based on the severity of EHS at presentation, none experienced a serious adverse event. In this cohort with rapid initiation of effective cooling, biochemical derangement appeared less severe than that reported in previous studies. Higher body mass index (BMI) was associated with a lower cooling rate across a range of values previously reported as potentially of clinical significance.ConclusionsThis case series supports recent updates to UK military guidance that ICWI should be more widely adopted for the treatment of EHS. Clinicians should be aware of likely patterns of blood test abnormalities in the days following EHS. Further work should seek to establish the impact of lower rates of cooling and develop strategies to optimise cooling in patients with higher BMI.

The current UK wave of COVID-19 continues to put significant strain on a health service also dealing with winter pressures. Reliable data are needed to inform decision-making in the ED as highlighted recently by the editor.1 However, the current published, presented and preprint studies do not use appropriate outcome measures to give the most useful information for those with ‘mild’ symptoms of COVID-19. Patients requiring supportive measures such as supplemental oxygen are necessarily admitted to hospital from the ED. However, those who present with mild symptoms and normal physiology require a decision to admit, discharge or refer to an ambulatory pathway. This strategy is already being used2 out of necessity but without formal assessments of individual risk. We know that the majority will make an uneventful recovery, never requiring hospital-based intervention.3 However, it is important to identify those at risk of deterioration. Patients who initially present with mild symptoms but …