Journal of Trauma and Acute Care Surgery - The differences between Military and Civilian Injury patterns
This question was asked by a student who is now a contractor teaching TCCC in the Middle East.
I have been asking around but nobody seems to know so far. So, in TCCC the guidelines for TXA is 1g in 100cc NS or LR over 10 min. Check. However. in remote areas (like the one I am working in) do not always have 100cc bags available. Most of the time they are 500cc bags or bottles. Due to supplies being very limited at times, I hate to waste 400cc of fluid every time I need TXA. Do you have any idea about the supporting evidence for 1g in 100cc? Am I able to mix a higher dose and give partial? I am just trying to think outside the box. Any thoughts?
Doc's Reply via Pharmacist consultation:
So really the bottom line is the concentration doesn’t matter. It can be given undiluted it can be given in a 100ml bag it can be given in a 1000ml bag. What matters is the total dose and the time. So whatever way you can get 1g in over ~10min in whatever way works the best for the particular crew, that’s what you should do.
Things to consider:
Why do we usually give TXA? We want to stop the body's process to breakdown the clots in the black box area in order to evacuate them to the most appropriate trauma center. We strive for permissive hypotension with these injury patterns. Would administering 1000ml of NS which has your TXA in it benefit the patient? Probably not. We are trying limit the amount of fluid we are giving the patient. I bring this up because we want you to think outside the box when you do not have 100cc piggyback bags for the TXA infusion. The point being made is that it does not matter what the concentration is, just that 1 gram is infused over 10 minutes but don't run with utilizing the 1,000ml bag for convenience of not carrying the 100cc bags. Be a thinking medic!
Why does TCCC guidelines use the antibiotics it uses....
Good questions. The answer is moxifloxacin appears to be a compromise choice, not a perfect choice. I have attached the 2011 IDSA guidelines for combat wound which goes into more detail on what to use when. I think moxi is a reasonable choice (I cant speak for the committee here but...)
1) moxi will cover for staph (MSSA) and coag neg staph, strep, Aeromonas spp (water contaminate), Acinetobacter and coliforms. Clinda does offer better MRSA (Moxi and cefixime do not), but neither clinda nor cefixime will cover Aeromonas or Acinetobacter. Clinda does not cover coliforms.
2) IDSA recommends narrow spectrum (gen 1 ceph) as base for combat injuries with exception of occular injury. (they do recommend addition of flagyl in some circumstances such as abd wounds). By using moxi you are meeting the abx within 3 hours guideline and you cover injury to almost all body areas with 1 pill.
3) Overall risk of tendonopathy with a single dose in an otherwise healthy young pt is actually pretty low. Check out this paper https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2921747 which sites risk of tendonopathy at 3.8 fold increase compared to other abx with avg age of incidence at 64 y/o.
4) Finally, you are correct. Meloxicam has a comparatively lower antiplatelet effect compared to other NSAIDs, not a zero effect. It is a choice of lesser evils. You get an additiive effect with the tylenol and meloxicam, might be able to avoid narcs or ketamine and so the payoff may be worth it.
This is just a quick answer, but I hope it helps. If not please let me know and I'll keep looking for you!
So recently asked why TCCC still recommends 14 gauge vs 10 gauge. Or for that matter why not some other device? A brief scan of literature didn't readily yield and back to back comparison of needle gauges. Anecdotally some say the 10 gauge is less likely to kink.
Additionally, there are now several new products which might be used.
1) ThoraQuick from Medical Tree (UK) - slick product with spring loaded blunt tip that allows penetration of skin whilst reducing risk of injury to underlying structures once in the thoracic cavity. It is essentially an improvement on the Turkel needle (see below) with an improved hub that allows for easy adhesion to the pt's chest wall. 2 ports on side of catheter as additional protection against occlusion. Length of catheter: 10cm, Size: 3mm ID (approx. 8 ga). Cost: 33.95 sterling or $47.96? (Not sold in US yet)
2) Turkel Needle: Also from Medical Tree. Spring loaded blunt tip. Catheter length: 3.5" (88.9cm), Size: 8 Fr (11.5 ga). Cost $60.99. (Available now)
3) 10 Fr (10 ga) Thoracotomy Tube with trocar. The IDF has been using a Vygon 10 Fr trocar with drain. This was originally designed for tube thorocostomy in neonates. The tube material is stiffer than the usual polyurethane in the 14 ga needle. The argument being it further helps prevent kinking and thus failures. A recent article (see below) discussed this but failed to directly compare the two devices and was limited by small sample size.
It is my opinion that the real reason CoTCCC may still be recommending the 14 gauge catheter may have a lot to do with cost. A 14 gauge needle/cath with hard case cost $9.99 from NAR. Even if you have to use multiple per pt, it's still cheaper, and it's a well established item in the supply chain. Add to that the lack of hard data showing superiority of other devices and it may be that a good solution now is better than a perfect solution later.
Beyond which is better there is some argument that perhaps we should abandon the needle altogether and go to finger thoracotomies both in the ED and in the field. See Scott Weingart's post about this as well as an article in JEMS below.
In the meantime I would say if you want to carry a 10 gauge, Turkel needle or the hot new ThoraQuick - go for it! There certainly is no data so suggest any of these options in inferior. And in the meantime if all you can get is a 14 gauge angiocath - do sweat it. Know the problems that may arise (kinking, clotting, risk of injury to intrathoracic structure) and anticipate the problems and have a plan.
Emerg Med J 2011;28:750-753
J. Chen et. al. " Needle thoracostomy for tension pneumothorax: the Israeli Defense Forces experience", Canadian Journal of Surgery, Vol 58 (3) Supplement 3, June 2015.
M Escott, et al. "Simple Thoracostomy: Moving Beyond Needle Decompression in Traumatic Cardiac Arrest" JEMS 39(4), MAR 2014.
Management of Open Pneumothorax in Tactical Combat Casualty Care: TCCC Guideline Change 13-02
|J Chen, R Nadler, D Schwartz, H Tein, A Cap, E Glassberg. What is the optimal device length and insertion site for needle thoracostomy in UK military casualties? Can J Surg. 2015 Jun;58(3 Suppl 3):S118-24.|
|File Size:||169 kb|
There is not much I could find on a brief search. The papers I found seem to support the established teaching that elevated triglycerides or cholesterol seem to promote inappropriate clotting increasing the risk of cardiovascular disease. The effect this has in trauma does not seem to be as well defined. Though there may be some effect on long term healing (not well studied) - the immediate problem and treatment of injury appears to be unchanged.
Papers included as matter of interest only- not great data....
R Krysiak, B Okopein, "Effect of simvastatin on hemostasis in patients with isolated hypertriglyceridemia". Pharmacology 92|(3-4):187-90. 2013.
- statin prolonged PT/PTT
W Chung, et. al. "Hyperlipidemia and statins affect neurological outcome in lumbar spine surgery." Int Journal of Environmental Research and Public Health". 12(1):402-13. 05 Jan 15.
Treatment with TXA ranged from < 72 hours to 6 weeks.
It was theorized that TXA would decrease the rebleed rate by preventing breakdown of the clot in the damaged vessel. In fact it did reduce rebleeding rates by 35%. However, TXA also increased the rate of cerebral ischemia and completely offset any benefit of preventing rebleeding. It is likely that the reason for worsening ischemi is prevention of recanalization of blocked blood vessels and the restoration of blood flow to surviving brain tissue.
There was no effect on rates of hydrocephalus.
Bottom line: This has little impact on TXA use for bleeding in trauma in a tactical environment- but if you should be asked, now you know why TXA is contraindicated in SAH.
M. Baharoglu, M Germans, G Rinkel, A Algra, M Vermeulen, J van Gijn, Y Roos, "Antifibrinolytic therapy for aneurysmal suabarachnoid haemorrhage." Cochrane Database Systematic Review, 30 Aug 2013.
T Eastin, C Snipes, R Seupaul, "Are antifibrinolytic agents effective in the treatment of aneurysmal subarachnoid hemorrhage?". Annals of Emergency Medicine V 64: 6, pp 658-659. 01 Dec 2014.
The results showed that TXA improved survival at 28 days from injury with an absolute risk reduction (death) of 1.5%. This may not seem like much but consider that there was no increased rate of death or serious side effects associated with the drug. This includes no increased risk of thromboembolic events (stroke, MI, PE, DVT).
There was no change in the rate or amount of blood transfusions required either, highlighting the importance of the drug as an adjunct and the continued need to get blood on board quickly.
This paper was donated to the public as an open document in an attempt to widen it's use and can be obtained at: http://www.journalslibrary.nihr.ac.uk/hta/volume-17/issue-10#abstract
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