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 [email protected]
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.”
[email protected]. 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: [email protected]
For up-to-date information about class cancellations due to weather, please follow us on Facebook at Facebook.com/BorgessTrauma
KERALA MEDICAL SERVICES CORPORATION LIMITED Passed Amount (Dept. of Health & Family Welfare, Govt of Kerala), Pending Amount ` 24,51,500.35 Tele Fax No : 0471-4015522,0471-2337353,0471-4019928. Total Amount ` 24,51,500.35 Website:www.kmscl.kerala.gov.in,E-mail:[email protected] STATEMENT OF INVOICES AND PAYMENTS FOR SUPPLY OF DRUGS AND SUPPLIES 25-F
Pat McKay RAW FOOD Basic Recipe Our own domestic cats and dogs must eat live food just as carnivores do in the wild to be at their optimum health. The Raw Food Basic Recipe for preparing meals for your cats and dogs is 75% raw ground meat and 25% raw ground or steamed/mashed vegetables . To prepare one cup (8 ounces) of food: 3/4 cup (6 ounces) of raw meat and 1/4 cup (2 ounces)