Prehospital assessment and management of postpartum haemorrhage- healthcare personnel’s experiences and perspectives

Background Postpartum hemorrhage (PPH) is a serious obstetric emergency, and one of the top five causes of maternal mortality globally. The most common causes of PPH include uterine atony, placental disorders, birth trauma and coagulation defects. Timely diagnosis and early management are critical to reduce morbidity, the need for blood transfusion or even mortality. External, manual aortic compression (AC) has been suggested as an intervention that reduce PPH and extend time for control of bleeding or resuscitation. This procedure is not commonly utilized by healthcare personnel. The incidence of home-births is increasing, and competence in PPH assessment and management is essential in prehospital personnel. The objective was to explore prehospital personnel’s competence in PPH and AC, utilizing different tools. Methods The study was conducted in a county in South-eastern Norway, including five ambulance stations. All prehospital personnel (n = 250) were invited to participate in a questionnaire study. The questionnaire included the PPH self-efficacy (PPHSE) and PPH collective efficacy (PPHCE) tools, as well as tool developed utilizing the Delphi technique. Descriptive statistics were used to analyze the quantitative data, while quantitative content analysis was used to analyse free-text responses. Results A total of 87 prehospital personnel responded to the questionnaire, 57.5% male, mean age 37.9 years. In total, 80.4% were ambulance workers and/or paramedics, and 96.6 and 97.7% respectively reported to need more education or training in PPH. Moreover, 82.8% reported having managed patient(s) with PPH, but only 2.9% had performed AC. Prehospital personnels’ responses varied extensively regarding knowledge about what PPH is, how to estimate and handle PPH, and how to perform AC. Mean self-efficacy varied from 3.3 to 5.6, while collective efficacy varied from 1.9 to 3.8. Conclusions This study indicates that prehospital personnel lack knowledge about PPH and AC, due to various responses to the developed questionnaire. Even though AC is an acknowledged intervention in PPH, few participants reported that this was utilized. Our findings emphasize the need for education and training in PPH and PPH handling generally, and in AC specifically.

Prehospital Handling of Postpartum Haemorrhage- Healthcare Personnel’s Experiences and Perspectives

Background: Postpartum hemorrhage (PPH) is a serious obstetric emergency, and one of the top five causes of maternal mortality globally. The most common causes of PPH include uterine atony, placental disorders, birth trauma and coagulation defects. Timely diagnosis and early management are critical to reduce morbidity, the need for blood transfusion or even mortality. External, manual aortic compression (AC) has been suggested as an intervention that reduce PPH and extend time for control of bleeding or resuscitation. This procedure is not commonly utilized by healthcare personnel. The incidence of home-births is increasing, and competence in PPH handling is essential in prehospital personnel. The objective was to explore prehospital personnel’s competence in PPH and AC, utilizing different tools. Methods: The study was conducted in a county in South-eastern Norway, including five ambulance stations. All prehospital personnel (n=250) were invited to participate in a questionnaire study. The questionnaire included the PPH self-efficacy (PPHSE) and PPH collective efficacy (PPHCE) tools, as well as a developed tool. Descriptive statistics were used to analyse the quantitative data, while quantitative content analysis was used to analyse free-text responses. Results: A total of 87 prehospital personnel responded to the questionnaire, 57.5 percent male, mean age 37.9 years. 80.4 percent were ambulance workers and/or paramedics, and 96.6 and 97.7 percent respectively reported to need more education or training in PPH. Results show that prehospital personnel lack knowledge about what PPH is, how to estimate and handle PPH, and how to perform AC. 82.8 percent reported having experienced PPH, but only 2.9 percent had performed AC. Mean self-efficacy varied from 3.3 to 5.6, while collective efficacy varied from 1.9 to 3.8. Educational background did not seem to have any impact on participants’ responses. Conclusions and implications: This study indicates that prehospital personnel lack knowledge about PPH and AC, and also report to need more education and training. Hence, PPH should be included in educational programs at all levels of the education, as well as in quality improvement initiatives. After the conduction of this study, prehospital personnel attended a digital course in PPH, as well as a practical course in AC.

RETROSPECTIVE OBSERVATIONAL STUDY OF 448 CEREBRAL CONTUSIONS IN A TERTIARY CARE TRAUMA CENTRE: ANALYSIS OF THEIR CLINICAL & RADIOLOGICAL PROGRESSION AND OUTCOME

Introduction: Traumatic cerebral contusion is one of the leading cause of morbidity and mortality in Neurosurgery. Patients can be either treated conservatively or surgically. Many patients who are treated conservatively may have CT scan progression and need surgery secondarily. This retrospective study was designed to study the clinical presentation and interventions predicting CT progression of hematoma and final outcome. Material and Methods: The study was conducted from April 2017 to December 2019 on all the patients of traumatic cerebral contusions, diagnosed by CT scan. Patients received either conservative treatment initially or underwent upfront surgery, and had at least one other CT scan during the acute hospitalization. Patients clinical history, CT progression and any intervention were noted. The patient’s disposition status was classified as discharged home, or to another institution, or whether the patient died. Results: Among the total 448 patients, 78.5% patients required surgery at presentation. 53.3% had a CT progression after repeat CT scan, among them 109 (48.8%) were operated. CT progression was seen more frequently in patients with coagulation abnormalities. Among patients with history of antiplatelet medication receiving platelet therapy, only 31% patients had CT progression. Patients who has poor initial GCS (Glasgow coma scale), underwent tracheostomy and had secondarily operated due to CT progression were discharged late. Conclusion: Coagulation defects was an important risk factor for CT progression. Platelet replacement therapy significantly decreased surgical intervention in patients with antiplatelet therapy. Poor initial GCS, secondary surgery and tracheostomy lengthened the hospital stay.

Coronavirus Disease 2019 and the Cerebrovascular‐Cardiovascular Systems: What Do We Know So Far?

The severe acute respiratory syndrome coronavirus 2 pandemic of 2019 to 2020 has resulted in multiple hospitalizations, deaths, and economic hardships worldwide. Although respiratory involvement in patients with coronavirus disease 2019 ( COVID ‐19) is well known, the potential cardiovascular and cerebrovascular manifestations are less understood. We performed a PubMed and Google Scholar search and reviewed relevant literature on COVID ‐19 and cardiovascular system involvement. Severe acute respiratory syndrome coronavirus 2 possesses high affinity for angiotensin‐converting enzyme 2 receptor, which is highly concentrated in the lungs and cardiovascular tissue, thereby provoking concern for cardiovascular involvement in COVID ‐19 cases. Preexisting cardiovascular and cerebrovascular disease has been shown in previous reports to be a risk factor for severe infection. On the basis of our review of published studies, COVID ‐19 patients may be more likely to experience acute cardiac injury, arrhythmia, coagulation defects, and acute stroke and are likely to have poorer outcomes as a result. As the COVID ‐19 pandemic continues, more data about potential cardiovascular and cerebrovascular manifestations of the disease are required.

Therapeutic Management of Snake Bite in a Rottweiler Dog

M Snakebite cases are more common in horses and dogs when compared to other animals such as cattle, sheep, and goats. Snake envenomation can be difficult to diagnose if the incident was not witnessed. Clinical signs may vary greatly depending on the species of snake involved, and the quantity and toxicity of the venom injected. Dogs are commonly presented with extensive edematous swelling, severe pain, ecchymosis, and discoloration of the skin in the affected area within several hours after the bite (Garg, 2002) The animals exhibit various symptoms like cardio-pulmonary dysfunction, local tissue damage, blood coagulation defects, ataxia etc, depending on type of snake bite (Bhardwaj, 2011). Systemic signs can vary and may include hypotension, shock, cardiac arrhythmias, bleeding disorders, ptyalism, nausea, vomiting, respiratory distress, mental confusion, rhabdomyolysis, and acute renal failure (Ananda et al., 2009). The snake bite with envenomation is a true emergency, and it needs rapid examination and prompt appropriate treatment. The current paper reports on the successful use of antihistamine together with anti-snake venoms, fluids, corticosteroids, and antibiotics with no untoward effects in a snake-bitten dog.

P5589Patterns of extended apixaban treatment for unprovoked venous thromboembolism in routine clinical practice

Background Current CHEST guidelines recommend extended anticoagulation therapy without a scheduled stop in patients with unprovoked VTE and low bleeding risk following initial anticoagulation treatment of 3 months. AMPLIFY-EXT suggests that extended treatment with apixaban beyond 6 months reduces the risk of recurrent VTE without increasing major bleeding rates. This study evaluated patterns of extended apixaban treatment among unprovoked VTE patients. Methods Utilizing 4 US commercial claims databases, this retrospective study assessed unprovoked VTE patients (VTE events that were not preceded by a provoked factor or event) who initiated apixaban within 30 days from the VTE event (01SEPT2014–31MAR2018). Patients were required to have ≥6 months continuous apixaban treatment (without a gap of >30 days). Characteristics of patients treated beyond 6 months and those who discontinued at 6 months were evaluated respectively. An additional analysis was conducted to assess proportion with apixaban treatment for ≥3 months. Results Among unprovoked VTE patients, 60.8% and 34.6% had apixaban treatment for ≥3 and ≥6 months, respectively. Of those treated for ≥6 months (3,015 after applying additional selection criteria), 75.6% continued treatment beyond 6 months and 24.4% discontinued at 6 months. Younger age and having thrombophilia were associated with a higher likelihood of treatment beyond 6 months (Table). Among patients with treatment beyond 6 months, 7.5% of patients switched from apixaban 5mg to 2.5mg, 36.5% discontinued therapy, and 1.1% switched to another oral anticoagulant (Figure). Baseline characteristics Variables Discontinued at 6 months Continued treatment beyond 6 months P-value N=735 N=2,280 Age, Mean (SD) 63.0 (15.2) 61.7 (14.3) 0.037 Gender – Female, n (%) 307 (41.8%) 892 (39.1%) 0.203 Setting of Unprovoked VTE Event – Ambulatory, n (%) 592 (80.5%) 1,834 (80.4%) 0.950 VTE Diagnosis – DVT Only, n (%) 494 (67.2%) 1,498 (65.7%) 0.452 Deyo-Charlson Comorbidity Index, Mean (SD) 1.3 (1.9) 1.3 (1.8) 0.305 Thrombophilia, n (%) 54 (7.3%) 296 (13.0%) <0.001 Coagulation Defects, n (%) 38 (5.2%) 153 (6.7%) 0.136 Baseline Bleed, n (%) 77 (10.5%) 210 (9.2%) 0.309 KM curve after 6 months of apixaban use Conclusion Among unprovoked VTE patients treated with apixaban, a large proportion did not receive ≥3 months of treatment. Although AMPLIFY-EXT showed beneficial effects of extended treatment, the percentage of patients with ≥6 months of treatment was low. Thrombophilia was the only meaningful predictor of treatment beyond 6 months. Acknowledgement/Funding This study was funded by Bristol-Myers Squibb and Pfizer Inc

The role of genetic thrombophilias in the development of fetal loss syndrome in women of Kursk region for 2012–2017

Введение. Тромбогенные мутации и полиморфизмы являются этиопатогенетическим триггером репродуктивных потерь и осложнений беременности: синдрома задержки внутриутробного роста плода, преэклампсии, преждевременной отслойки нормально расположенной плаценты. Имплантация, инвазия трофобласта и дальнейшее функционирование плаценты объективно нарушаются в случае генетических дефектов свертывания. Цель исследования: оценка распространенности, роли врожденных тромбогенных мутаций и полиморфизмов и их сочетаний в генезе синдрома потери плода у женщин Курской области за 20122017 гг. Материалы и методы. Изучена клиникоанамнестическая характеристика, морфология плаценты, распространенность полиморфизма генов фолатного цикла и системы гемостаза у женщин, проживающих на территории Курской области, с синдромом потери плода: один или более самопроизвольных выкидышей или неразвивающихся беременностей на сроке 10 и более недель мертворождение неонатальная смерть 3 и более самопроизвольных выкидыша до 8 нед эмбрионального развития. Результаты. Наше исследование показало, что у женщин данного региона с ранними потерями беременности практически в 60 наблюдений выявлено 3 и более тромбогенных полиморфизмов, преимущественно генов фолатного цикла (р 0,001). Для пациенток с репродуктивными потерями во второй половине беременности характерно наличие 2 полиморфизмов, в основном, генов фолатного цикла и ингибитора активатора плазминогена 1 (р 0,001). Заключение. Необходима разработка индивидуальных подходов к тактике ведения женщин с синдромом потери плода в Курской области. Introduction. Thrombophilic mutations and polymorphisms are ethiopathological triggers of reproductive losses and pregnancy complications: intrauterine growth restriction, preeclampsia, premature abruption of normally located placenta. Implantation, trophoblast invasion and further placental functioning are objectively impaired in the presence of genetic coagulation defects. Aim: to assess the prevalence and role of congenital thrombogenic mutations and polymorphisms and their combinations in the genesis of fetal loss syndrome in women of Kursk region for 20122017. Materials and methods. We studied clinical and anamnestic characteristic, placental morphology, prevalence of genetic polymorphisms in folate cycle and hemostasis in women with fetal loss syndrome (one or more spontaneous miscarriages or undeveloped pregnancies for 10 or more weeks stillbirth neonatal death 3 or more spontaneous miscarriages up to 8 weeks of embryonic development) in Kursk region. Results. Our study showed that 3 and more thrombophilic polymorphisms (mainly genes of the folate cycle) were revealed in 60 women with early pregnancy losses in this region (р 0,001). The presence of 2 polymorphisms (mainly genes of the folate cycle and plasminogen activator inhibitor 1) were characteristic of patients with reproductive losses in the second half of pregnancy (р 0,001). Conclusion. It is necessary to develop individual approaches to the management of women with fetal loss syndrome in Kursk region.