Browsing by Subject "Hemorrhage"

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    Correction to: Quantification of myocardial hemorrhage using T2* cardiovascular magnetic resonance at 1.5 T with ex-vivo validation
    (Elsevier, 2022-02-07) Chen, Yinyin; Ren, Daoyuan; Guan, Xingmin; Yang, Hsin‑Jung; Liu, Ting; Tang, Richard; Ho, Hao; Jin, Hang; Zeng, Mengsu; Dharmakumar, Rohan; Radiology and Imaging Sciences, School of Medicine
    In the original publication [1] an error was introduced in the affiliations of Yinyin Chen due to a misunderstanding during the publication process. The incorrect and correct affiliations are listed below. The original article has been updated.
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    Evaluation of Tranexamic Acid and Calcium Chloride in Major Traumas in a Prehospital Setting: A Narrative Review
    (Wolters Kluwer, 2023) Bell, Kameron T.; Salmon, Chase M.; Purdy, Benjamin A.; Canfield, Scott G.; Anatomy, Cell Biology and Physiology, School of Medicine
    Excessive blood loss in the prehospital setting poses a significant challenge and is one of the leading causes of death in the United States. In response, emergency medical services (EMS) have increasingly adopted the use of tranexamic acid (TXA) and calcium chloride (CaCl2) as therapeutic interventions for hemorrhagic traumas. Tranexamic acid functions by inhibiting plasmin formation and restoring hemostatic balance, while calcium plays a pivotal role in the coagulation cascade, facilitating the conversion of factor X to factor Xa and prothrombin to thrombin. Despite the growing utilization of TXA and CaCl2 in both prehospital and hospital environments, a lack of literature exists regarding the comparative effectiveness of these agents in reducing hemorrhage and improving patient outcomes. Notably, Morgan County Indiana EMS recently integrated the administration of TXA with CaCl2 into their treatment protocols, offering a valuable opportunity to gather insight and formulate updated guidelines based on patient-centered outcomes. This narrative review aims to comprehensively evaluate the existing evidence concerning the administration of TXA and CaCl2 in the prehospital management of hemorrhages, while also incorporating and analyzing data derived from the co-administration of these medications within the practices of Morgan County EMS. This represents the inaugural description of the concurrent use of both TXA and CaCl2 to manage hemorrhages in the scientific literature.
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    Life-Threatening Bleeding in Children: A Prospective Observational Study
    (Wolters Kluwer, 2021) Leonard, Julie C.; Josephson, Cassandra D.; Luther, James F.; Wisniewski, Stephen R.; Allen, Christine; Chiusolo, Fabrizio; Davis, Adrienne L.; Finkelstein, Robert A.; Fitzgerald, Julie C.; Gaines, Barbara A.; Goobie, Susan M.; Hanson, Sheila J.; Hewes, Hilary A.; Johnson, Laurie H.; McCollum, Mark O.; Muszynski, Jennifer A.; Nair, Alison B.; Rosenberg, Robert B.; Rouse, Thomas M.; Sikavitsas, Athina; Singleton, Marcy N.; Steiner, Marie E.; Upperman, Jeffrey S.; Vogel, Adam M.; Wills, Hale; Winkler, Margaret K.; Spinella, Philip C.; Surgery, School of Medicine
    Objectives: The purpose of our study was to describe children with life-threatening bleeding. Design: We conducted a prospective observational study of children with life-threatening bleeding events. Setting: Twenty-four childrens hospitals in the United States, Canada, and Italy participated. Subjects: Children 0-17 years old who received greater than 40 mL/kg total blood products over 6 hours or were transfused under massive transfusion protocol were included. Interventions: Children were compared according bleeding etiology: trauma, operative, or medical. Measurements and main results: Patient characteristics, therapies administered, and clinical outcomes were analyzed. Among 449 enrolled children, 55.0% were male, and the median age was 7.3 years. Bleeding etiology was 46.1% trauma, 34.1% operative, and 19.8% medical. Prior to the life-threatening bleeding event, most had age-adjusted hypotension (61.2%), and 25% were hypothermic. Children with medical bleeding had higher median Pediatric Risk of Mortality scores (18) compared with children with trauma (11) and operative bleeding (12). Median Glasgow Coma Scale scores were lower for children with trauma (3) compared with operative (14) or medical bleeding (10.5). Median time from bleeding onset to first transfusion was 8 minutes for RBCs, 34 minutes for plasma, and 42 minutes for platelets. Postevent acute respiratory distress syndrome (20.3%) and acute kidney injury (18.5%) were common. Twenty-eight-day mortality was 37.5% and higher among children with medical bleeding (65.2%) compared with trauma (36.1%) and operative (23.8%). There were 82 hemorrhage deaths; 65.8% occurred by 6 hours and 86.5% by 24 hours. Conclusions: Patient characteristics and outcomes among children with life-threatening bleeding varied by cause of bleeding. Mortality was high, and death from hemorrhage in this population occurred rapidly.
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    Monotherapy Anticoagulation to Expedite Home Treatment of Patients Diagnosed With Venous Thromboembolism in the Emergency Department: A Pragmatic Effectiveness Trial
    (American Heart Association, 2021) Kline, Jeffrey A.; Adler, David H.; Alanis, Naomi; Bledsoe, Joseph R.; Courtney, Daniel M.; d’Etienne, James P.; Diercks, Deborah B.; Garrett, John S.; Jones, Alan E.; Mackenzie, David C.; Madsen, Troy; Matuskowitz, Andrew J.; Mumma, Bryn E.; Nordenholz, Kristen E.; Pagenhardt, Justine; Runyon, Michael S.; Stubblefield, William B.; Willoughby, Christopher B.; Emergency Medicine, School of Medicine
    Background: The objective was to test if low-risk emergency department patients with vitamin K antagonist (venous thromboembolism [VTE]; including venous thrombosis and pulmonary embolism [PE]) can be safely and effectively treated at home with direct acting oral (monotherapy) anticoagulation in a large-scale, real-world pragmatic effectiveness trial. Methods: This was a single-arm trial, conducted from 2016 to 2019 in accordance with the Standards for Reporting Implementation Studies guideline in 33 emergency departments in the United States. Participants had newly diagnosed VTE with low risk of death based upon either the modified Hestia criteria, or physician judgment plus the simplified PE severity index score of zero, together with nonhigh bleeding risk were eligible. Patients had to be discharged within 24 hours of triage and treated with either apixaban or rivaroxaban. Effectiveness was defined by the primary efficacy and safety outcomes, image-proven recurrent VTE and bleeding requiring hospitalization >24 hours, respectively, with an upper limit of the 95% CI for the 30-day frequency of VTE recurrence below 2.0% for both outcomes. Results: We enrolled 1421 patients with complete outcomes data, including 903 with venous thrombosis and 518 with PE. The recurrent VTE requiring hospitalization occurred in 14/1421 (1.0% [95% CI, 0.5%-1.7%]), and bleeding requiring hospitalization occurred in 12/1421 (0.8% [0.4%-1.5%). The rate of severe bleeding using International Society for Thrombosis and Haemostasis criteria was 2/1421 (0.1% [0%-0.5%]). No patient died, and serious adverse events occurred in 2.5% of venous thrombosis patients and 2.3% of patients with PE. Medication nonadherence was reported by patients in 8.0% (6.6%-9.5%) and was associated with a risk ratio of 6.0 (2.3-15.2) for VTE recurrence. Among all patients diagnosed with VTE in the emergency department during the period of study, 18% of venous thrombosis patients and 10% of patients with PE were enrolled. Conclusions: Monotherapy treatment of low-risk patients with venous thrombosis or PE in the emergency department setting produced a low rate of bleeding and VTE recurrence, but may be underused. Patients with venous thrombosis and PE should undergo risk-stratification before home treatment. Improved patient adherence may reduce rate of recurrent VTE.
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    Outpatient treatment of low-risk venous thromboembolism with monotherapy oral anticoagulation: patient quality of life outcomes and clinician acceptance
    (Dove Press, 2016-04-15) Kline, Jeffrey A.; Kahler, Zachary P.; Beam, Daren M.; Department of Emergency Medicine, IU School of Medicine
    BACKGROUND: Oral monotherapy anticoagulation has facilitated home treatment of venous thromboembolism (VTE) in outpatients. OBJECTIVES: The aim of this study was to measure efficacy, safety, as well as patient and physician perceptions produced by a protocol that selected VTE patients as low-risk patients by the Hestia criteria, and initiated home anticoagulation with an oral factor Xa antagonist. METHODS: Patients were administered the Venous Insufficiency Epidemiological and Economic Study Quality of life/Symptoms questionnaire [VEINEs QoL/Sym] and the physical component summary [PCS] from the Rand 36-Item Short Form Health Survey [SF36]). The primary outcomes were VTE recurrence and hemorrhage at 30 days. Secondary outcomes compared psychometric test scores between patients with deep vein thrombosis (DVT) to those with pulmonary embolism (PE). Patient perceptions were abstracted from written comments and physician perceptions specific to PE outpatient treatment obtained from structured survey. RESULTS: From April 2013 to September 2015, 253 patients were treated, including 67 with PE. Within 30 days, 2/253 patients had recurrent DVT and 2/253 had major hemorrhage; all four had DVT at enrollment. The initial PCS scores did not differ between DVT and PE patients (37.2±13.9 and 38.0±12.1, respectively) and both DVT and PE patients had similar improvement over the treatment period (42.2±12.9 and 43.4±12.7, respectively), consistent with prior literature. The most common adverse event was menorrhagia, present in 15% of women. Themes from patient-written responses reflected satisfaction with increased autonomy. Physicians' (N=116) before-to-after protocol comfort level with home treatment of PE increased 48% on visual analog scale. CONCLUSION: Hestia-negative VTE patients treated with oral monotherapy at home had low rates of VTE recurrence and bleeding, as well as quality of life measurements similar to prior reports.
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    Pathophysiological and behavioral deficits in developing mice following rotational acceleration-deceleration traumatic brain injury
    (Company of Biologists:, 2018-01-30) Wang, Guoxiang; Zhang, Yi Ping; Gao, Zhongwen; Shields, Lisa B. E.; Li, Fang; Chu, Tianci; Lv, Huayi; Moriarty, Thomas; Xu, Xiao-Ming; Yang, Xiaoyu; Shields, Christopher B.; Cai, Jun; Neurological Surgery, School of Medicine
    Abusive head trauma (AHT) is the leading cause of death from trauma in infants and young children. An AHT animal model was developed on 12-day-old mice subjected to 90° head extension-flexion sagittal shaking repeated 30, 60, 80 and 100 times. The mortality and time until return of consciousness were dependent on the number of repeats and severity of the injury. Following 60 episodes of repeated head shakings, the pups demonstrated apnea and/or bradycardia immediately after injury. Acute oxygen desaturation was observed by pulse oximetry during respiratory and cardiac suppression. The cerebral blood perfusion was assessed by laser speckle contrast analysis (LASCA) using a PeriCam PSI system. There was a severe reduction in cerebral blood perfusion immediately after the trauma that did not significantly improve within 24 h. The injured mice began to experience reversible sensorimotor function at 9 days postinjury (dpi), which had completely recovered at 28 dpi. However, cognitive deficits and anxiety-like behavior remained. Subdural/subarachnoid hemorrhage, damage to the brain-blood barrier and parenchymal edema were found in all pups subjected to 60 insults. Proinflammatory response and reactive gliosis were upregulated at 3 dpi. Degenerated neurons were found in the cerebral cortex and olfactory tubercles at 30 dpi. This mouse model of repetitive brain injury by rotational head acceleration-deceleration partially mimics the major pathophysiological and behavioral events that occur in children with AHT. The resultant hypoxia/ischemia suggests a potential mechanism underlying the secondary rotational acceleration-deceleration-induced brain injury in developing mice.
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    Quantification of myocardial hemorrhage using T2* cardiovascular magnetic resonance at 1.5T with ex-vivo validation
    (Elsevier, 2021-09-30) Chen, Yinyin; Ren, Daoyuan; Guan, Xingmin; Yang, Hsin‑Jung; Liu, Ting; Tang, Richard; Ho, Hao; Jin, Hang; Zeng, Mengsu; Dharmakumar, Rohan; Radiology and Imaging Sciences, School of Medicine
    Background: T2* cardiovascular magnetic resonance (CMR) is commonly used in the diagnosis of intramyocardial hemorrhage (IMH). For quantifying IMH with T2* CMR, despite the lack of consensus studies, two different methods [subject-specific T2* (ssT2*) and absolute T2* thresholding (aT2* < 20 ms)] are interchangeably used. We examined whether these approaches yield equivalent information. Methods: ST elevation myocardial infarction (STEMI) patients (n = 70) were prospectively recruited for CMR at 4-7 days post revascularization and for 6-month follow up (n = 43). Canines studies were performed for validation purposes, where animals (n = 20) were subject to reperfused myocardial infarction (MI) and those surviving the MI (n = 16) underwent CMR at 7 days and 8 weeks and then euthanized. Both in patients and animals, T2* of IMH and volume of IMH were determined using ssT2* and aT2* < 20 ms. In animals, ex-vivo T2* CMR and mass spectrometry for iron concentration ([Fe]Hemo) were determined on excised myocardial sections. T2* values based on ssT2* and absolute T2* threshold approaches were independently regressed against [Fe]Hemo and compared. A range of T2* cut-offs were tested to determine the optimized conditions relative to ssT2*. Results: While both approaches showed many similarities, there were also differences. Compared to ssT2*, aT2* < 20 ms showed lower T2* and volume of IMH in patients and animals independent of MI age (all p < 0.005). While T2* determined from both methods were highly correlated against [Fe]Hemo (R2 = 0.9 for both), the slope of the regression curve for ssT2* was significantly larger as compared to aT2* < 20 ms (0.46 vs. 0.32, p < 0.01). Further, slightly larger absolute T2* cut-offs (patients: 23 ms; animals: 25 ms) showed similar IMH characteristics compared to ssT2*. Conclusion: Current quantification methods have excellent capacity to identify IMH, albeit the T2*of IMH and volume of IMH based on aT2* < 20 ms are smaller compared to ssT2*. Thus the method used to quantify IMH from T2* CMR may influence the diagnosis for IMH.
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    Resonant acoustic rheometry for assessing plasma coagulation in bleeding patients
    (Springer Nature, 2025-02-11) Li, Weiping; Bunch, Connor M.; Zackariya, Sufyan; Patel, Shivani S.; Buckner, Hallie; Condon, Shaun; Walsh, Matthew R.; Miller, Joseph B.; Walsh, Mark M.; Hall, Timothy L.; Jin, Jionghua; Stegemann, Jan P.; Deng, Cheri X.; Emergency Medicine, School of Medicine
    Disordered hemostasis associated with life-threatening hemorrhage commonly afflicts patients in the emergency department, critical care unit, and perioperative settings. Rapid and sensitive hemostasis phenotyping is needed to guide administration of blood components and hemostatic adjuncts to reverse aberrant hemostasis. Here, we report the use of resonant acoustic rheometry (RAR), a technique that quantifies the viscoelastic properties of soft biomaterials, for assessing plasma coagulation in a cohort of 38 bleeding patients admitted to the hospital. RAR captured the dynamic characteristics of plasma coagulation that were dependent on coagulation activators or reagent conditions. RAR coagulation parameters correlated with TEG reaction time and TEG functional fibrinogen, especially when stratified by comorbidities. A quadratic classifier trained on selective RAR parameters predicted transfusion of fresh frozen plasma and cryoprecipitate with modest to high overall accuracy. While these results demonstrate the feasibility of RAR for plasma coagulation and utility of a machine learning model, the relative small number of patients, especially the small number of patients who received transfusion, is a limitation of this study. Further studies are need to test a larger number of patients to further validate the capability of RAR as a cost-effective and sensitive hemostasis assay to obtain quantitative data to guide clinical-decision making in managing severely hemorrhaging patients.
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    Systematic review and meta-analysis of outcomes in patients with suspected pulmonary embolism
    (American Society of Hematology, 2021-04-27) Patel, Parth; Patel, Payal; Bhatt, Meha; Braun, Cody; Begum, Housne; Nieuwlaat, Robby; Khatib, Rasha; Martins, Carolina C.; Zhang, Yuan; Etxeandia-Ikobaltzeta, Itziar; Varghese, Jamie; Alturkmani, Hani; Bahaj, Waled; Baig, Mariam; Kehar, Rohan; Mustafa, Ahmad; Ponnapureddy, Rakesh; Sethi, Anchal; Thomas, Merrill; Wooldridge, David; Lim, Wendy; Bates, Shannon M.; Lang, Eddy; Le Gal, Grégoire; Haramati, Linda B.; Kline, Jeffrey A.; Righini, Marc; Wiercioch, Wojtek; Schünemann, Holger; Mustafa, Reem A.; Emergency Medicine, School of Medicine
    Prompt evaluation and therapeutic intervention of suspected pulmonary embolism (PE) are of paramount importance for improvement in outcomes. We systematically reviewed outcomes in patients with suspected PE, including mortality, incidence of recurrent PE, major bleeding, intracranial hemorrhage, and postthrombotic sequelae. We searched the Cochrane Central Register of Controlled Trials, MEDLINE, and Embase for eligible studies, reference lists of relevant reviews, registered trials, and relevant conference proceedings. We included 22 studies with 15 865 patients. Among patients who were diagnosed with PE and discharged with anticoagulation, 3-month follow-up revealed that all-cause mortality was 5.69% (91/1599; 95% confidence interval [CI], 4.56-6.83), mortality from PE was 1.19% (19/1597; 95% CI, 0.66-1.72), recurrent venous thromboembolism (VTE) occurred in 1.38% (22/1597; 95% CI: 0.81-1.95), and major bleeding occurred in 0.90% (2/221%; 95% CI, 0-2.15). In patients with a low pretest probability (PTP) and negative D-dimer, 3-month follow-up revealed mortality from PE was 0% (0/808) and incidence of VTE was 0.37% (4/1094; 95% CI: 0.007-0.72). In patients with intermediate PTP and negative D-dimer, 3-month follow-up revealed that mortality from PE was 0% (0/2747) and incidence of VTE was 0.46% (14/3015; 95% CI: 0.22-0.71). In patients with high PTP and negative computed tomography (CT) scan, 3-month follow-up revealed mortality from PE was 0% (0/651) and incidence of VTE was 0.84% (11/1302; 95% CI: 0.35-1.34). We further summarize outcomes evaluated by various diagnostic tests and diagnostic pathways (ie, D-dimer followed by CT scan).