Pathophysiology of Trauma-Induced Coagulopathy

There is no standard definition for trauma-induced coagulopathy (TIC). However, it could be defined as an abnormal hemostatic response secondary to trauma. The terms "early TIC" and "late TIC" have been recently suggested. "Early TIC" would refer to the inability to achieve effective hemostasis exacerbating an uncontrolled bleeding in a shocked patient with ischemia-reperfusion damage (bleeding phenotype) and takes place usually early after injury, whereas "late TIC" would represent a hypercoagulable state after surviving a severe tissue injury, that would contribute to thromboembolic events and multiorgan failure (MOF), (thrombotic phenotype), occurring typically hours after the trauma insult though it could be delayed for days. In addition, severe tissue injury when there is no associated shock could be followed by an early hypercoagulable state, representing an evolutionary maladaptive response of a physiologic mechanism created to increase clot formation and prevent bleeding. Therefore, TIC is not a uniform phenotype, ranging from bleeding to pro-thrombotic profiles. This current concept of TIC is mainly based on the recognition of TIC as a unique clotting disorder following trauma in which alterations in the endothelial function, fibrinolysis regulation and platelet behavior after major trauma are the main cornerstones.

Near-fatal Panton-Valentine leukocidin-positive Staphylococcus aureus pneumonia, shock and complicated extracorporeal membrane oxygenation cannulation: A case report

BACKGROUND

Panton-Valentine leukocidin (PVL) is an exotoxin secreted by Staphylococcus aureus (S. aureus), responsible for skin and soft tissue infections. As a cause of severe necrotising pneumonia, it is associated with a high mortality rate. A rare entity, the epidemiology of PVL S. aureus (PVL-SA) pneumonia as a complication of influenza coinfection, particularly in young adults, is incompletely understood.

CASE SUMMARY

An adolescent girl presented with haemoptysis and respiratory distress, deteriorated rapidly, with acute respiratory distress syndrome (ARDS) and profound shock requiring extensive, prolonged resuscitation, emergency critical care and venovenous extracorporeal membrane oxygenation (ECMO). Cardiac arrest and a rare complication of ECMO cannulation necessitated intra-procedure extracorporeal cardiopulmonary resuscitation, i.e., venoarterial ECMO. Coordinated infectious disease, microbiology and Public Health England engagement identified causative agents as PVL-SA and influenza A/H3N2 from bronchial aspirates within hours. Despite further complications of critical illness, the patient made an excellent recovery with normal cognitive function. The coordinated approach of numerous multidisciplinary specialists, nursing staff, infection control, specialist cardiorespiratory support, hospital services, both adult and paediatric and Public Health are testimony to what can be achieved to save life against expectation, against the odds. The case serves as a reminder of the deadly nature of PVL-SA when associated with influenza and describes a rare complication of ECMO cannulation.

CONCLUSION

PVL-SA can cause severe ARDS and profound shock, with influenza infection. A timely coordinated multispecialty approach can be lifesaving.

Development and implementation of a COVID-19 near real-time traffic light system in an acute hospital setting

Common causes of death in COVID-19 due to SARS-CoV-2 include thromboembolic disease, cytokine storm and adult respiratory distress syndrome (ARDS). Our aim was to develop a system for early detection of disease pattern in the emergency department (ED) that would enhance opportunities for personalised accelerated care to prevent disease progression. A single Trust's COVID-19 response control command was established, and a reporting team with bioinformaticians was deployed to develop a real-time traffic light system to support clinical and operational teams. An attempt was made to identify predictive elements for thromboembolism, cytokine storm and ARDS based on physiological measurements and blood tests, and to communicate to clinicians managing the patient, initially via single consultants. The input variables were age, sex, and first recorded blood pressure, respiratory rate, temperature, heart rate, indices of oxygenation and C-reactive protein. Early admissions were used to refine the predictors used in the traffic lights. Of 923 consecutive patients who tested COVID-19 positive, 592 (64%) flagged at risk for thromboembolism, 241/923 (26%) for cytokine storm and 361/923 (39%) for ARDS. Thromboembolism and cytokine storm flags were met in the ED for 342 (37.1%) patients. Of the 318 (34.5%) patients receiving thromboembolism flags, 49 (5.3% of all patients) were for suspected thromboembolism, 103 (11.1%) were high-risk and 166 (18.0%) were medium-risk. Of the 89 (9.6%) who received a cytokine storm flag from the ED, 18 (2.0% of all patients) were for suspected cytokine storm, 13 (1.4%) were high-risk and 58 (6.3%) were medium-risk. Males were more likely to receive a specific traffic light flag. In conclusion, ED predictors were used to identify high proportions of COVID-19 admissions at risk of clinical deterioration due to severity of disease, enabling accelerated care targeted to those more likely to benefit. Larger prospective studies are encouraged.

Inflammatory and microbiological associations with near-fatal asthma requiring extracorporeal membrane oxygenation

Extracorporeal membrane oxygenation (ECMO) has developed as a critical tool permitting lung protection in severe respiratory failure. Its use was largely confined to acute respiratory distress syndrome [1]; however, as technology has advanced, it is now used in a range of respiratory diseases, including asthma. In the context of near-fatal asthma exacerbations, ECMO provides a management strategy for difficult-to-ventilate patients who would otherwise be unlikely to survive. Importantly, in asthma, traditional mechanical ventilation strategies can be associated with volutrauma and barotrauma due to the high pressures required in the presence of severe bronchospasm [2]. To date, there is a paucity of data for ECMO use in acute asthma and it is unknown whether specific clinical or inflammatory characteristics are associated with the need for ECMO.

Patients with near-fatal asthma requiring ECMO are more likely to be younger and female and are also likely to have positive viral and fungal isolates on bronchoalveolar lavage when compared to those receiving conventional mechanical ventilationhttp://bit.ly/2S38SaC

Hospital costs of out-of-hospital cardiac arrest patients treated in intensive care; a single centre evaluation using the national tariff-based system

OBJECTIVES

There is a scarcity of literature reporting hospital costs for treating out of hospital cardiac arrest (OOHCA) survivors, especially within the UK. This is essential for assessment of cost-effectiveness of interventions necessary to allow just allocation of resources within the National Health Service. We set out primarily to calculate costs stratified against hospital survival and neurological outcomes. Secondarily, we estimated cost effectiveness based on estimates of survival and utility from previous studies to calculate costs per quality adjusted life year (QALY).

SETTING

We performed a single centre (London) retrospective review of in-hospital costs of patients admitted to the intensive care unit (ICU) following return of spontaneous circulation (ROSC) after OOHCA over 18 months from January 2011 (following widespread introduction of targeted temperature management and primary percutaneous intervention).

PARTICIPANTS

Of 69 successive patients admitted over an 18-month period, survival and cerebral performance category (CPC) outcomes were obtained from review of databases and clinical notes. The Trust finance department supplied ICU and hospital costs using the Payment by Results UK system.

RESULTS

Of those patients with ROSC admitted to ICU, survival to hospital discharge (any CPC) was 33/69 (48%) with 26/33 survivors in CPC 1-2 at hospital discharge. Cost per survivor to hospital discharge (including total cost of survivors and non-survivors) was £50,000, cost per CPC 1-2 survivor was £65,000. Cost and length of stay of CPC 1-2 patients was considerably lower than CPC 3-4 patients. The majority of the costs (69%) related to intensive care. Estimated cost per CPC 1-2 survivor per QALY was £16,000.

CONCLUSIONS

The costs of in-hospital patient care for ICU admissions following ROSC after OOHCA are considerable but within a reasonable threshold when assessed from a QALY perspective.

Undiagnosed phaeochromocytoma masquerading as eclampsia

The authors report the case of a previously well 34-year-old woman presenting with a hypertensive crises and a grand-mal seizure following elective caesarean section. Initial treatment of extreme hypertension, of a presumed eclamptic aetiology, with magnesium and labetalol was complicated by intermittent profound hypotensive episodes. This was accompanied by severe biventricular failure and fluctuating systemic vascular resistance. Abdominal ultrasound revealed a left suprarenal mass. A diagnosis of phaeochromocytoma was confirmed on abdominal CT and urinary assays. The patient was stabilised with α and β blockade, was successfully extubated and subsequently had the tumour surgically excised. The cardiac function returned to normal on echocardiography and she has made a complete recovery.

Holiday travel: planning ahead

Unfamiliar physical conditions and pathogens are encountered during foreign travel. Ill effects can be avoided by careful planning and this is particularly important for the elderly, children and for travellers with chronic medical problems.