Tranexamic acid use in emergency medicine

The most common cause of potentially preventable trauma deaths is hemorrhage. Therefore, it is crucial to understand the mechanisms regulating bleeding and clotting. The physiological mechanisms that control the coagulation process are called the coagulation cascade. In this study, we analyzed the medical literature for published articles on the use of TXA for bleeding. The MEDLINE electronic database was searched for. The keywords we have used were: “tranexamic acid”, “bleeding”, “hemorrhage”, “treatment”, “prevention”, “patient blood management”, “anti-fibrinolytic”, “surgery”, “surgery”, “trauma”, “injury” and “traumatic brain injury”. When managing the traumatic patient, time is of the essence and the same holds true for the TXA application. The largest study regarding the use of TXA in the emergency medicine CRASH-2 found that the administration of TXA within 3 hours following injury significantly reduces the mortality and that every 15-min delay in administering TXA results in increased bleeding and decreased survival by 10%, offering no benefit if administered after 3 hours. In summary, TXA is a safe and reliable agent which greatly increases the survival rate in traumatic patients suffering blood loss, reducing mortality while being safe

P2Y12 antagonist ticagrelor inhibits the release of procoagulant extracellular vesicles from activated platelets

Background: Activated platelets release platelet extracellular vesicles (PEVs). Adenosine diphosphate(ADP) receptors P2Y1 and P2Y12 both play a role in platelet activation, The present hypothesis hereinis that the inhibition of these receptors may affect the release of PEVs.Methods: Platelet-rich plasma from 10 healthy subjects was incubated with saline, P2Y1 antagonistMRS2179 (100 μM), P2Y12 antagonist ticagrelor (1 μM), and a combination of both antagonists.Platelets were activated by ADP (10 μM) under stirring conditions at 37°C. Platelet reactivity wasassessed by impedance aggregometry. Concentrations of PEVs– (positive for CD61 but negative forP-selectin and phosphatidylserine) and PEVs+ (positive for all) were determined by a state-of-the-artflow cytometer. Procoagulant activity of PEVs was measured by a fibrin generation test.Results: ADP-induced aggregation (57 ± 13 area under curve {AUC] units) was inhibited 73%by the P2Y1 antagonist, 86% by the P2Y12 antagonist, and 95% when combined (p < 0.001 for all).The release of PEVs– (2.9 E ± 0.8 × 108/mL) was inhibited 48% in the presence of both antagonists(p = 0.015), whereas antagonists alone were ineffective. The release of PEVs+ (2.4 ± 1.6 × 107/mL)was unaffected by the P2Y1 antagonist, but was 62% inhibited by the P2Y12 antagonist (p = 0.035),and 72% by both antagonists (p = 0.022). PEVs promoted coagulation in presence of tissue factor.Conclusions: Inhibition of P2Y1 and P2Y12 receptors reduces platelet aggregation and affects therelease of distinct subpopulations of PEVs. Ticagrelor decreases the release of procoagulant PEVs fromactivated platelets, which may contribute to the observed clinical benefits in patients treated with ticagrelor

Catheter-directed therapy to treat intermediate- and high-risk pulmonary embolism: Personal experience and review of the literature

Pulmonary embolism (PE) is the third leading cause of cardiovascular death in the western world. Prompt recognition, risk stratification, and individualized treatment are crucial to improve outcomes in patients with PE. Anticoagulation alone is a sufficient therapeutic option in low-risk patients, whereas primary reperfusion with systemic thrombolysis (ST) is usually chosen in high-risk patients. The choice of treatment in intermediate-risk patients is complex and depends on the clinical presentation. Catheter-directed therapy (CDTh) includes all therapies delivered via a catheter placed in the branches of the pulmonary arteries directly into the thrombus. Because ST bears a high risk of major bleeding and numerous patients have contraindications to ST, CDTh is an alternative to ST in intermediate- and high-risk PE patients. CDTh includes local thrombolysis using low-dose alteplase, ultrasound-assisted thrombolysis, and mechanical fragmentation and aspiration of the thrombi, as well as their combinations. In this review article, we have summarized devices and technical details for CDTh, discussed the efficacy and safety of CDTh in comparison to ST in previous clinical trials, and outlined future research directions regarding CDTh, both based on the literature and our personal experience from the local PE Response Team of the Center for the Management of Pulmonary Embolism (CELZAT) in Warsaw

Should targeted temperature management be used in cardiogenic shock patients? Systematic review and meta-analysis

Background: Therapeutic hypothermia, or targeted temperature management (TTM), is a strategy of reducing the core body temperature of survivors of sudden cardiac arrest, cardiogenic shock (CS) or stroke. Therefore, a systematic literature review and meta-analysis were performed to tackle the question about whether the implementation of TTM is actually beneficial for patients with CS. Methods: Study was designed as a systematic review and meta-analysis. PubMed, Cochrane Library, Web of Science and Scopus were searched from these databases inception to July 17, 2022. Eligible studies were those comparing TTM and non-TTM treatment in CS patients. Data were pooled with the Mantel-Haenszel method. Results. Thirty-day mortality was reported in 3 studies. Polled analysis of 30-day mortality was 44.2% for TTM group and 48.9% for non-TTM group (risk ratio: 0.90; 95% confidence interval: 0.75 to 1.08; p = 0.27). Other mortality follow-up periods showed also no statistically significant differences (p > 0.05). The occurrence of adverse events in the studied groups also did not show statistically significant differences between TTM and non-TTM groups (p > 0.05 for myocardial infarction, stent thrombosis, sepsis, pneumonia, stroke or bleeding events). Conclusions: The present analysis shows no significant benefit of TTM in patients with CS. Moreover, no statistically significant increase of the incidence of adverse effects was found. However, further randomized studies with higher sample size and greater validity are needed to determine if TTM is worth implementing in CS patients