Hemorrhage

Dengue, the most prevalent arthropod-borne viral disease of humans, is caused by four serotypes of dengue virus (DENV 1-4). Although all four DENV serotypes cause a range of illness, defining precisely which clinical characteristics are associated with the distinct serotypes has been elusive. A cross-sectional study was conducted on 984 and 313 hospitalized children with confirmed DENV infections during two time periods, respectively, in the same hospitals in Nicaragua: a 3-year period (1999-2001) when DENV-2 accounted for 96% of the viruses identified, and the 2003 dengue season when DENV-1 predominated (87% of identified serotypes). When the two periods were compared, more shock (OR 1.91, 95% CI 1.35-2.71) and internal hemorrhage (OR 2.05, CI 1.16-3.78) were observed in the period when DENV-2 predominated, whereas increased vascular permeability was associated to a greater degree with the DENV-1 period (OR 2.36, CI 1.80-3.09). Compared with the DENV-2 period, the DENV-1 season was...

Given the recent success of emergency tourniquets, limb exsanguination is no longer the most common cause of preventable death on the battlefield; hemorrhage amenable to truncal tourniquets now is. The purpose of the present study is to discuss the gaps today in battlefield hemorrhage control and candidate solutions in order to stimulate the advancement of prehospital combat casualty care. A literature review, a market survey of candidate devices, a request for devices, and an analysis of the current situation regarding battlefield hemorrhage control were performed. Hemorrhage control for wounds in the junction between the trunk and the limbs and neck is a care gap in the current war, and, of these, the pelvic (including buttock and groin proximal to the inguinal ligament) area is the most common. Historical and recent reports give background information indicating that truncal tourniquets are plausible devices for controlling junctional hemorrhage on the battlefield. A request for ...

The reduction of maternal deaths is a key international development goal. Evidence-based health policies and programmes aiming to reduce maternal deaths need reliable and valid information. We undertook a systematic review to determine the distribution of causes of maternal deaths. We selected datasets using prespecified criteria, and recorded dataset characteristics, methodological features, and causes of maternal deaths. All analyses were restricted to datasets representative of populations. We analysed joint causes of maternal deaths from datasets reporting at least four major causes (haemorrhage, hypertensive disorders, sepsis, abortion, obstructed labour, ectopic pregnancy, embolism). We examined datasets reporting individual causes of death to investigate the heterogeneity due to methodological features and geographical region and the contribution of haemorrhage, hypertensive disorders, abortion, and sepsis as causes of maternal death at the country level. 34 datasets (35,197 ...

Approximately 22 million children in the United States sustain traumatic injuries every year, the etiologies of which vary with age as well as social and environmental factors. If not managed properly, these injuries can have a significant impact on future growth and development. Evaluation of facial injuries presents a unique diagnostic challenge in this population, as differences from adult anatomy and physiology can result in vastly different injury profiles. The increased ratio of the cranial mass relative to the body leaves younger patients more vulnerable to craniofacial trauma. It is essential that the treating physician be aware of these variations to properly assess and treat this susceptible and fragile patient population and ensure optimal outcomes. This article reviews the proper emergency department assessment and treatment of facial fractures in the pediatric population as well as any associated injuries, with particular emphasis on initial patient stabilization, radio...

This article concerning the pharmacokinetics and pharmacodynamics of vitamin K antagonists (VKAs) is part of the Seventh American College of Chest Physicians Conference on Antithrombotic and Thrombolytic Therapy: Evidence-Based Guidelines. The article describes the antithrombotic effect of VKAs, the monitoring of anticoagulation intensity, the clinical applications of VKA therapy, and the optimal therapeutic range of VKAs, and provides specific management recommendations. Grade 1 recommendations are strong, and indicate that the benefits do, or do not, outweigh the risks, burdens, and costs. Grade 2 suggests that individual patient's values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2004; 126:179S-187S). Among the key recommendations in this article are the following: for dosing of VKAs, we suggest the initiation of oral anticoagulation therapy with doses between 5 and 10 mg for the first 1 or 2 days for most individuals, with subsequent dosing based on the international normalized ratio (INR) response (Grade 2B). In the elderly and in other patient subgroups with an elevated bleeding risk, we suggest a starting dose at < or = 5 mg (Grade 2C). We recommend basing subsequent doses after the initial two or three doses on the results of INR monitoring (Grade 1C). The article also includes several specific recommendations for the management of patients with INRs above the therapeutic range and for patients requiring invasive procedures. For example, in patients with mild to moderately elevated INRs without major bleeding, we suggest that when vitamin K is to be given it be administered orally rather than subcutaneously (Grade 1A). For the management of patients with a low risk of thromboembolism, we suggest stopping warfarin therapy approximately 4 days before they undergo surgery (Grade 2C). For patients with a high risk of thromboembolism, we suggest stopping warfarin therapy approximately 4 days before surgery, to allow the INR to return to normal, and beginning therapy with full-dose unfractionated heparin or full-dose low-molecular-weight heparin as the INR falls (Grade 2C). In patients undergoing dental procedures, we suggest the use of tranexamic acid mouthwash (Grade 2B) or epsilon amino caproic acid mouthwash without interrupting anticoagulant therapy (Grade 2B) if there is a concern for local bleeding. For most patients who have a lupus inhibitor, we suggest a therapeutic target INR of 2.5 (range, 2.0 to 3.0) [Grade 2B]. In patients with recurrent thromboembolic events with a therapeutic INR or other additional risk factors, we suggest a target INR of 3.0 (range, 2.5 to 3.5) [Grade 2C]. As models of anticoagulation monitoring and management, we recommend that clinicians incorporate patient education, systematic INR testing, tracking, and follow-up, and good communication with patients concerning results and dosing decisions (Grade 1C+).

PURPOSE: To identify optimum international normalized ratio (INR) levels and required warfarin doses and anticoagulation-related complications in patients following mechanical prosthetic valve replacement.MATERIALS AND METHODS: Five hundred and seven patients were prospectively followed up for 10 years (2008.5 patient-years). Anticoagulation-related complications were classified into hemorrhage and thromboembolism.RESULTS: Two hundred and ninety-two (57.6%) were males and 215 (42.4%) were females with a mean age of 29.5 +/- 11.32 years. A total of 268 (52.9%) patients had mitral, 96 (18.9%) had aortic and mitral, and 76 (15%) had aortic valve replacement (AVR). Valves implanted totaled 345 (68%) ball and cage, 126 (24.9%) bileaflet, and 36 (7.1%) single disc. There were 10,669 total visits, with mean INR 2.6 +/- 0.59 and mean warfarin 5.17 +/- 1.6 mg. Sixty-four (3.2% per patient-years) events occurred during follow-up, of which 23 (1.13% per patient-years) events were due to thromboembolism and 41 (2.04% per patient-years) to bleeding. Atrial fibrillation occurred in 12 (52.4%) patients having thromboembolic events and in 24 (58.5%) suffering from bleeding complications. Among thromboembolic events, valve thrombosis occurred in 9 patients (0.44% per patient-years) and cerebrovascular accidents (CVAs) in 14 (0.69% per patient-years). Atrial fibrillation was present in 7 (77.8%) patients in the valve thrombosis group and in 5 (35.7%) in the CVA group. Of 41 bleeding events, 8 (0.39% per patient-years) were minor episodes, 20 (0.99% per patient-years) were major episodes, and severe hemorrhage occurred in 5 (0.34% per patient-years). Intracranial hemorrhage leading to CVA was seen in 8 patients (0.34% per patient-years). There were 22 (1.1% per patient-years) fatal hemorrhages and 15 (0.74% per patient-years) fatal thromboembolic events. In-hospital mortality was 25 (4.9%), and 62 (12.2%) were late deaths; of these, 37 (7.3%) were anticoagulation related.CONCLUSIONS: Anticoagulation for mechanical heart valve replacement can be managed with INR levels of 2-2.5 with acceptable hemorrhagic and thromboembolic events.

The perioperative interruption of oral anticoagulants present a challenge for the hematologist and to the physician who should perform the procedure as well as. The handling situations that arise in these recommendations crop up from the literature and the experiences of the
authors. The critical point to stop treatment is to avoid re-thrombosis and, at the same time to prevent bleeding complication. To establish the best conditions in this balance prevention / security, we must keep in mind several factors: the type of surgery, patient characteristics and pharmacokinetics of oral anticoagulants; coumarins (acenocoumarol, warfarin) and the new antithrombin drugs: dabigatran [Pradaxa, Boehringer Ingleheim] and anti factor Xa: rivaroxaban [Xarelto, Bayer] and apixaban [Eliquis, Bristol-Myers Squibb / Pfizer]. Based on these data, we suggest perioperative discontinuation scheme.