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news from cardiology, neuroscience & trauma services at Borgess Winter 2014
CRASH–2 trial suggested that TXA was neither beneficial nor harmful in the treatment of traumatic intracranial hemorrhage and did not seem to increase the risk of stroke3. Because CRASH–2 was not designed to evaluate the efficacy of TXA usage in traumatic ICH, a large Traditionally, dictum regarding the management of the randomized-control trial is currently recruiting patients traumatized patient has emphasized the “Golden Hour” as the point in time interventions can have the most The TXA protocol adopted by both Borgess Medical profound impact on patient survival. Current research in Center and West Michigan Air Care includes administration resuscitation and the coagulopathy of trauma has greatly of 1 gram of TXA within the first hour after trauma and improved our understanding of the nature of hemorrhagic subsequent administration of an additional 1 gram of shock. Recognizing the deleterious effects of over- TXA over eight hours. TXA is available in both oral and aggressive crystalloid resuscitation, importance of early intravenous forms and is currently available at both Borgess and balanced blood product transfusion, and the need for Medical Center and on the Air Care helicopters. prompt control of hemorrhage are now the hallmarks of quality trauma care. Recently Borgess Medical Center and The rapid expansion of our understanding of hemorrhagic West Michigan Air Care have incorporated the protocolized shock, coagulopathy, and point-of-care coagulation testing have profoundly changed our transfusion strategies. For an up-to-date review of thromboelastography (TEG) please Patients suffering hemorrhagic shock often develop the refer to both Dr. Rohs’ article on TEG in this issue and so-called “coagulopathy of trauma” as a direct result of massive hemorrhage and resuscitation without adequate repletion of the clotting factors. Balanced massive 1 Tranexamic Acid for Trauma Patients: A Critical Review of the Literature. The Journal of Trauma, Infection, and Critical Care 2011; 71(1): S9–S14 transfusion protocols help alleviate this iatrogenic 2 Effects of Tranexamic Acid on Death, Vascular Occlusive Events, and Blood coagulopathy. During the course of resuscitation, fibrinogen Transfusion in Trauma Patients with Significant Hemorrhage (CRASH-2): levels become depleted and the fibrinolytic arm of the A Randomized, Placebo-controlled Trial. The Lancet 2010; 376(9734): 23–32 coagulation cascade becomes poorly controlled resulting 3 Effect of Tranexamic Acid in Traumatic Brain Injury: A Nested Randomized, in accelerated and inappropriate clot lysis; leading to Placebo-controlled Trial (CRASH-2 Intracranial Bleeding Study). BMJ 2011; delayed or continued bleeding. Transexamic acid (TXA), a synthetic lysine derivative, has long been used to reduce 4 Case Scenario: Management of Trauma-induced Coagulopathy in a Severe Blunt peri-operative hemorrhage in cardiac, orthopedic and liver Trauma Patient. Anesthesiology 2013; 119: 191–200.
surgery. TXA, an anti-fibrinolytic, works by binding to both plasminogen and plasmin and de-activating them. Plasmin is directly responsible for the degradation of fibrin, the clotting factor most responsible for clot strength. The result of TXA administration is a slowing of fibrinolysis TEG is a coagulation test which has historically been widely used in cardiac surgery and transplantation. Recently, this test has become used much more frequently The CRASH–2 trial, a randomized control trial, enrolled in trauma resuscitation and management, and it promises 20,211 patients and evaluated the efficacy of TXA in to be useful. Borgess began to use this technology in some hemorrhagic shock. This study demonstrated a significant trauma evaluations within the past year, and I believe it decrease in all-cause mortality in the TXA group compared will likely replace many traditional coagulation studies, to placebo [ 1,463 (14.5%) vs 1,613(16.0%), 95% CI not only in trauma, but in many other acute care situations 0.85 – 0.97; p = 0.0035]2. Subgroup analysis of the Less than 1 ml of blood is placed in a tiny spinning cup with a pin in the middle. As clot forms in the cup, it begins to transfer measurable energy to the pin, creating a tracing Article from Journal of Trauma Nursing The following is the abstract from an article authored by our multidisciplinary Trauma Research Team and is based on a study that involved nurses from Borgess Medical Center. Intimate partner violence (IPV) causes serious injury and death each year in the United States. Estimates show that up to 16% of patients are current victims of IPV. The Joint Commission requires patients admitted to the hospital be screened for IPV. Nurses play a pivotal role in this screening process. The goal of this study was to identify nurses’ attitudes and perceived barriers to screening. A survey was distributed to clinical nurses The measurements of time to beginning clot (R), time to caring for inpatients at a level I trauma center. A total of 20mA tracing amplitude (K), the alpha angle and greatest 82.6% of nurses reported taking care of 2 or less victims clot strength (MA) all measure the function of different of IPV in the last year, and 45.8% reported not caring for parts of the clotting cascade. This includes factor function, a single IPV victim in the last year. Most nurses in this fibrinogen content and platelet number and function, study have reported that screening for IPV is important, and TEG gives rapid information to guide transfusion that it is their responsibility to screen their patients, and requirements. The majority of the trauma related literature that they experience few work environment barriers to has been focused on the use of this test to guide massive screening. Among study respondents, the most common identified barrier to screening is the lack of training.
Of more interest in Kalamazoo is the unique ability of this test to measure platelet function. We do not have large The team continues to do research surrounding the topic numbers of penetrating trauma patients with extensive of intimate partner violence, and Mican DeBoer, BSN, transfusion needs, but we do have lots of patients on will be presenting their most recent project at the Eastern antiplatelet agents who are admitted with intracranial Association for the Surgery of Trauma’s national conference hemorrhage. TEG can give enormously valuable information regarding the effects that specific agents have on the platelet function of the individual patient. It then For more information on this important topic and to read allows surgeons to define strategies most likely to reverse the article in its entirety use the following reference: them, which can be a very problematic puzzle in patients DeBoer, M.I., Kothari, R., Kothari, C., Koestner, A.L., and using the newer antiplatelet agents and anticoagulants.
Rohs, Jr, T. (2013). What Are Barriers to Nurses Screening Stay tuned for more. I believe that the medical emergency for Intimate Partner Violence? Journal Of Trauma Nursing, physicians, critical care teams, obstetricians and others are 20(3), 155-160. doi:10.1097/JTN.0b013e3182a7b5c3 going to discover the utility of this technology. It will likely supplant the traditional tests we have long used in many phases of acute care medicine. Reference: http://cdn.lifeinthefastlane.com/wp-content/uploads/2013/01/ TEG-21.jpg Verify time and date of “last known well” This is different than when “the symptoms were first Within the United States, falls amongst older adults have become a monumental issue. Currently, for older adults, falls are the leading cause of both fatal and nonfatal injuries. On average, one in every three adults over the age • A patient awakening with any stroke symptoms (verify the last the time the patient used the neurological function of 65 suffer from a fall each year (CDC, 2013). Borgess which is now affected, ie before bed or during a night time Trauma Services, in partnership with the Area Agency on Aging, is now offering a new fall prevention program to the Kalamazoo County community. A Matter of Balance: • Noticing symptoms when attempting to get out of a chair (also verify the last time their functioning was normal).
Managing Concerns About Falls is currently one of only two evidence-based fall prevention programs in the United • Speech changes noticed after a long period of silence States. It was developed at the Roybal Center at Boston (use the last time the person spoke normally).
University and focuses on viewing falls as controllable, setting goals to increase activity levels, making specific Any patient with stroke-like symptoms within the past changes to reduce fall risks, and exercising routinely to increase overall strength and balance. The program consists of eight, two hour sessions. Since adding this presentation • A list of medications (especially any blood thinners to their Injury Prevention roster, Trauma Services has been able to educate several older adults on fall prevention at • A recent medical history (attention to any bleeding a variety of organizations, including Friendship Village, problems, major surgeries, major traumas, aneurysms, Portage Senior Center and Borgess Health & Fitness Center. seizures, strokes or heart attacks).
For more information on this program please contact Morgan Robinson at 226.7075. • Check blood pressure and glucose (a high blood pressure can limit tPA treatment and a low glucose level can mimic Reference: Centers for Disease Control. (2013). Falls Among Older Adults: An Overview. Retrieved from http://www.cdc.gov/homeandrecreationalsafety/Falls/adultfalls.html. as soon as possibleTime is crucial, when an potential tPA case is identified, Stroke certified hospitals, such as the Borgess Medical Center, provide excellent stroke care, in part, because of self assessment measures. From first responders all the way to rehabilitation and community education, we collect data and According to the American Heart Association, Emergency frequently review it. We recognize that, to provide quality Medical Services transporting directly to a PCI-capable care, we must be dynamic. We make adjustments to meet hospital for primary PCI is the recommended triage the changing needs of the real world. Below are four EMS- strategy for patients with STEMI, with an ideal FMC-to- related measures that we follow to improve stroke care: device time system goal of 90 minutes or less. As Borgess strives to bring this population of patients directly to the cardiovascular laboratory, we encourage EMS to observe The hallmark of stroke, is the sudden onset of neurological
the case, if possible. You can earn up to one medical credit. symptoms. A simple way to catch 80% of strokes is to use Contact Julie Maleitzke at juliemaleitzke@borgess.com
the FAST test. “F” stands for facial droop. Have the person smile and observe. “A” stands for arm weakness. Have the person hold both arms in the air, in watch for weakness. Borgess also offers EMS education. If you have any “S” stands for speech changes. Start a conversation with suggestion on specific topics of interest, regarding STEMI/ the person and notice if they have problems such as word ACS patients, contact Sandy Wilson at (269) 226.7050 or
finding, nonsensical speech or slurring of words. “T” stands for “time is brain.” sandy.wilson@borgess.com.
February 26
CPR Recertification (need exact count to be compliant with student to instructor ratio)Fitness: Exercise programs and nutrition advice August 27
LEC Auditorium
September 24

All classes meet on a Wednesday evening near the end of the month at 6 p.m. at Borgess Medical Center.
Dinner is served so please RSVP one week before the event by emailing: juliemaleitzke@borgess.com
For up-to-date information about class cancellations due to weather, please follow us on Facebook at
Facebook.com/BorgessTrauma

Source: http://www.borgesshealth.org/files/ems/lifelines.pdf