Early fibrinogen concentrate therapy for major haemorrhage in trauma (E-FIT 1): results from a UK multi-centre, randomised, double blind, placebo-controlled pilot trial.

BACKGROUND: There is increasing interest in the timely administration of concentrated sources of fibrinogen to patients with major traumatic bleeding. Following evaluation of early cryoprecipitate in the CRYOSTAT 1 trial, we explored the use of fibrinogen concentrate, which may have advantages of more rapid administration in acute haemorrhage. The aims of this pragmatic study were to assess the feasibility of fibrinogen concentrate administration within 45 minutes of hospital admission and to quantify efficacy in maintaining fibrinogen levels ≥ 2 g/L during active haemorrhage. METHODS: We conducted a blinded, randomised, placebo-controlled trial at five UK major trauma centres with adult trauma patients with active bleeding who required activation of the major haemorrhage protocol. Participants were randomised to standard major haemorrhage therapy plus 6 g of fibrinogen concentrate or placebo. RESULTS: Twenty-seven of 39 participants (69%; 95% CI, 52-83%) across both arms received the study intervention within 45 minutes of admission. There was some evidence of a difference in the proportion of participants with fibrinogen levels ≥ 2 g/L between arms (p = 0.10). Fibrinogen levels in the fibrinogen concentrate (FgC) arm rose by a mean of 0.9 g/L (SD, 0.5) compared with a reduction of 0.2 g/L (SD, 0.5) in the placebo arm and were significantly higher in the FgC arm (p < 0.0001) at 2 hours. Fibrinogen levels were not different at day 7. Transfusion use and thromboembolic events were similar between arms. All-cause mortality at 28 days was 35.5% (95% CI, 23.8-50.8%) overall, with no difference between arms. CONCLUSIONS: In this trial, early delivery of fibrinogen concentrate within 45 minutes of admission was not feasible. Although evidence points to a key role for fibrinogen in the treatment of major bleeding, researchers need to recognise the challenges of timely delivery in the emergency setting. Future studies must explore barriers to rapid fibrinogen therapy, focusing on methods to reduce time to randomisation, using 'off-the-shelf' fibrinogen therapies (such as extended shelf-life cryoprecipitate held in the emergency department or fibrinogen concentrates with very rapid reconstitution times) and limiting the need for coagulation test-based transfusion triggers. TRIAL REGISTRATION: ISRCTN67540073 . Registered on 5 August 2015

Severe traumatic injury during long duration spaceflight: Light years beyond ATLS

Traumatic injury strikes unexpectedly among the healthiest members of the human population, and has been an inevitable companion of exploration throughout history. In space flight beyond the Earth's orbit, NASA considers trauma to be the highest level of concern regarding the probable incidence versus impact on mission and health. Because of limited resources, medical care will have to focus on the conditions most likely to occur, as well as those with the most significant impact on the crew and mission. Although the relative risk of disabling injuries is significantly higher than traumatic deaths on earth, either issue would have catastrophic implications during space flight. As a result this review focuses on serious life-threatening injuries during space flight as determined by a NASA consensus conference attended by experts in all aspects of injury and space flight

Sports Orthopedics

ACL injury involves sagittal plane and rotatory instability;with its reconstruction aimed at restoring this instability. There remains room for improvement in long-term clinical outcomes and preventing recurrent instability. Therefore, it is important to understand the biomechanical parameters that require attention during reconstruction to optimize patient outcomes. In the setting of ACL injury, the armamentarium of the orthopaedic surgeon includes multiple physical examination maneuvers, quantitative measures of knee instability, and advanced imaging to determine the pattern of instability and inform surgical planning. The pivot shift phenomenon, as a measure of rotatory instability, is one of the key biomechanical parameters which must be restored after reconstruction and which is not fully restored by non-anatomic ACL reconstruction. Anatomic ACL reconstruction represents the gold-standard, as it has demonstrated enhanced ability to restore rotatory instability, reduce anterior tibial translation, and improve patient reported outcomes compared to non-anatomic techniques. Repair of concurrent ligamentous and meniscal injuries, as well as possible extra-articular procedures, may enhance the restoration of rotatory stability. Lateral extra-articular tenodesis may be indicated in patients with high pivot shift, who play sports with aggressive rotatory motion, or who have generalized laxity. This article details the approach to knee instability following ACL rupture and the optimal techniques to restore the rotatory stability post-reconstruction.KEY WORDS: ACL Reconstruction, ACL Instability, Knee Instability, Multi-Ligament Knee Injury, Lateral Extra-Articular Tenodesi