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BACKGROUND: Pulmonary vascular microthrombi are a proposed mechanism of COVID-19 respiratory failure. We hypothesized that early administration of tissue plasminogen activator (tPA) followed by therapeutic heparin would improve pulmonary function in these patients. RESEARCH QUESTION: Does tPA improve pulmonary function in severe COVID-19 respiratory failure, and is it safe? STUDY DESIGN AND METHODS: Adults with COVID-19-induced respiratory failure were randomized from May14, 2020 through March 3, 2021, in two phases. Phase 1 (n = 36) comprised a control group (standard-of-care treatment) vs a tPA bolus (50-mg tPA IV bolus followed by 7 days of heparin; goal activated partial thromboplastin time [aPTT], 60-80 s) group. Phase 2 (n = 14) comprised a control group vs a tPA drip (50-mg tPA IV bolus, followed by tPA drip 2 mg/h plus heparin 500 units/h over 24 h, then heparin to maintain aPTT of 60-80 s for 7 days) group. Patients were excluded from enrollment if they had not undergone a neurologic examination or cross-sectional brain imaging within the previous 4.5 h to rule out stroke and potential for hemorrhagic conversion. The primary outcome was Pao2 to Fio2 ratio improvement from baseline at 48 h after randomization. Secondary outcomes included Pao2 to Fio2 ratio improvement of > 50% or Pao2 to Fio2 ratio of ≥ 200 at 48 h (composite outcome), ventilator-free days (VFD), and mortality. RESULTS: Fifty patients were randomized: 17 in the control group and 19 in the tPA bolus group in phase 1 and eight in the control group and six in the tPA drip group in phase 2. No severe bleeding events occurred. In the tPA bolus group, the Pao2 to Fio2 ratio was significantly (P < .017) higher than baseline at 6 through 168 h after randomization; the control group showed no significant improvements. Among patients receiving a tPA bolus, the Pao2 to Fio2 ratio at 48 h (16.9% [interquartile range (IQR), -8.3% to 36.8%] vs 29.8% [IQR, 4.5%-88.7%]; P = .11), the composite outcome (11.8% vs 47.4%; P = .03), VFD (0.0 [IQR, 0.0-9.0] vs 12.0 [IQR, 0.0-19.0]; P = .11), and in-hospital mortality (41.2% vs 21.1%; P = .19) did not reach statistically significant differences when compared with those of control participants. The patients who received a tPA drip did not experience benefit. INTERPRETATION: The combination of tPA bolus plus heparin is safe in severe COVID-19 respiratory failure. A phase 3 study is warranted given the improvements in oxygenation and promising observations in VFD and mortality. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT04357730; URL: www.clinicaltrials.gov.

BACKGROUND Trauma teams are often faced with patients on antithrombotic drugs, which is challenging when bleeding occurs. We sought to compare the effects of different antithrombotic medications on head injury severity and hypothesized that antithrombotic reversal would not improve mortality in severe TBI patients. METHODS An EAST-sponsored prospective, multi-centered, observational study of 15 trauma centers was performed. Patient demographics, injury burden, comorbidities, antithrombotic agents, and reversal attempts were collected. Outcomes of interest were head injury severity and in-hospital mortality. RESULTS Analysis was performed on 2793 patients. The majority of patients were on aspirin (ASA, 46.1%). Patients on a platelet chemoreceptor blocker (P2Y12) had the highest mean injury severity score (ISS, 9.1 ± 8.1). Patients taking P2Y12 inhibitors ± ASA, and ASA + warfarin had the highest head AIS mean (1.2 ± 1.6). On risk adjusted analysis, warfarin + ASA was associated with a higher head AIS (OR 2.43; 95% CI: 1.34-4.42) after controlling for injury severity score (ISS), Charlson Comorbidity Index (CCI), initial Glasgow Coma Score (I-GCS) and initial systolic blood pressure (I-SBP). Among patients with severe TBI (head AIS > 3) on antiplatelet therapy, reversal with desmopressin (DDAVP) and/or platelet transfusion did not improve survival (82.9% reversal vs 90.4% none, p = 0.30). In severe TBI patients taking Xa inhibitors who received prothrombin complex concentrate (PCC), survival was not improved (84.6% reversal vs 84.6% none, p = 0.68). With risk adjustment as described previously, mortality was not improved with reversal attempts (antiplatelet agents OR 0.83. 85% CI: 0.12-5.9, p = 0.85, Xa inhibitors OR 0.76, 95% CI: 0.12-4.64, p = 0.77). CONCLUSIONS Reversal attempts appear to confer no mortality benefit in severe TBI patients on antiplatelet agents or Xa inhibitors. Combination therapy was associated with severity of head injury among patients taking preinjury antithrombotic therapy, with ASA + warfarin possessing the greatest risk. LEVEL OF EVIDENCE Level II; prognostic. STUDY TYPE prospective observation.

Trauma teams are often faced with patients on antithrombotic (AT) drugs, which is challenging when bleeding occurs. We sought to compare the effects of different AT medications on head injury severity and hypothesized that AT reversal would not improve mortality in severe traumatic brain injury (TBI) patients.An Eastern Association for the Surgery of Trauma-sponsored prospective, multicentered, observational study of 15 trauma centers was performed. Patient demographics, injury burden, comorbidities, AT agents, and reversal attempts were collected. Outcomes of interest were head injury severity and in-hospital mortality.Analysis was performed on 2,793 patients. The majority of patients were on aspirin (acetylsalicylic acid [ASA], 46.1%). Patients on a platelet chemoreceptor blocker (P2Y12) had the highest mean Injury Severity Score (9.1 ± 8.1). Patients taking P2Y12 inhibitors ± ASA, and ASA-warfarin had the highest head Abbreviated Injury Scale (AIS) mean (1.2 ± 1.6). On risk-adjusted analysis, warfarin-ASA was associated with a higher head AIS (odds ratio [OR], 2.43; 95% confidence interval [CI], 1.34-4.42) after controlling for Injury Severity Score, Charlson Comorbidity Index, initial Glasgow Coma Scale score, and initial systolic blood pressure. Among patients with severe TBI (head AIS score, ≥3) on antiplatelet therapy, reversal with desmopressin (DDAVP) and/or platelet transfusion did not improve survival (82.9% reversal vs. 90.4% none, p = 0.30). In severe TBI patients taking Xa inhibitors who received prothrombin complex concentrate, survival was not improved (84.6% reversal vs. 84.6% none, p = 0.68). With risk adjustment as described previously, mortality was not improved with reversal attempts (antiplatelet agents: OR 0.83; 85% CI, 0.12-5.9 [p = 0.85]; Xa inhibitors: OR, 0.76; 95% CI, 0.12-4.64; p = 0.77).Reversal attempts appear to confer no mortality benefit in severe TBI patients on antiplatelet agents or Xa inhibitors. Combination therapy was associated with severity of head injury among patients taking preinjury AT therapy, with ASA-warfarin possessing the greatest risk.Prognostic, level II.

Hemorrhagic shock remains the leading cause of potentially preventable death following traumatic injuries. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) has demonstrated promising results in the control of non-compressible torso hemorrhage. The purpose of this review is to summarize the indications, procedural techniques, and complications of REBOA in order to help define practice management guidelines. Recent studies suggest that REBOA is advantageous in aiding hemodynamic stabilization as a bridge to definitive hemorrhage control. REBOA is a feasible option for non-compressible torso hemorrhage as well as traumatic cardiac arrest and has the potential to improve morbidity and mortality in select patient populations. Despite favorable emerging data, varying results in the literature indicate the need for further high-quality reproducible data and multicenter trials to identify the ideal clinical scenarios for REBOA. This review discusses special considerations and future directions for next generation REBOA use.

The objective of this study was to describe the atypical presentation of combined intrapleural and extrapleural hematomas in patients on anticoagulant therapy and explain the best workup and treatment for this pathology. This case report details the presentation, initial treatment, initial workup, and subsequent final treatment and workup of an elderly female patient that arrived at our trauma facility after suffering a blunt force trauma. The patient received anticoagulation therapy for her comorbidities prior to this incident. The outcome of interest was to better understand the best diagnostic and treatment modalities for treating combined intrapleural and extrapleural hematomas.

Background: We present the case of two brothers with identical mechanisms of injury presenting simultaneously, one with SARS-Cov-2 respiratory failure and the other in hemorrhagic shock. Summary: Healthcare globally and in the United States met novel challenges during the unprecedented severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) health crisis. The effect of SARS-CoV-2 on hospital and health care delivery systems has been widely reported. Elective surgical procedures were suspended; however, trauma and acute care services remained active and faced unique challenges during this pandemic. Trauma patients by their nature of injury require rapid assessment and treatment to include invasive emergency operations. Not only do trauma centers have to adapt to limited resources and new procedures limiting exposure, they are also met with the confounding issue of trauma patients concomitantly presenting with SARS-CoV-2 respiratory illness. Conclusion: Trauma care providers must now contend with SARS-CoV-2 on the differential for patients presenting with trauma. This is demonstrated by our case of two brothers with identical mechanisms of injury presenting simultaneously, one in shock from respiratory failure and the other hemorrhagic.

Background Following blunt abdominal trauma, bowel injuries are often missed on admission computed tomography (CT) scan. Methods Multicenter retrospective analysis of 176 adults with moderate-critical blunt abdominal trauma and admission CT scan who underwent operative exploration. Patients with a bowel injury missed on CT (n = 36, 20%) were compared to all other patients (n = 140, 80%). Results The missed injury group had greater incidence free fluid without solid organ injury on CT scan (44% vs. 25%, p = 0.038) and visceral adhesions (28% vs. 6%, p = 0.001). Independent predictors of missed bowel injury included prior abdominal inflammation (OR 3.74, 95% CI 1.37–10.18), CT evidence of free fluid in the absence of solid organ injury (OR 2.31, 95% CI 1.03–5.19) and intraoperative identification of visceral adhesions (OR 4.46, 95% CI 1.52–13.13). Conclusions Patients with visceral adhesive disease and indirect evidence of bowel injury on CT scan were more likely to have occult bowel injury.

Patient: Female, 36 Final Diagnosis: Thyroid hemorrhage Symptoms: Shortness of breath Medication: — Clinical Procedure: Thyroidectomy Specialty: Surgery Objective: Rare disease Background: Spontaneous goiter hemorrhage is a rare entity that can lead to life-threatening respiratory compromise. Goiter hemorrhages are usually due to effects of anticoagulation or neoplastic processes. The hormonal effects of pregnancy may also lead to such life-threatening goiter hemorrhages in the immediate postpartum period. Case Report: We report the case of a 36-year-old woman who complained of progressive neck swelling as well as eventual shortness of breath in the immediate postpartum period. Computed tomography scans and ultrasound of the neck revealed an enlarged and heterogenous thyroid with airway compression. The patient underwent an emergent subtotal thyroidectomy to alleviate the mass effect on the airway. Upon resection, the thyroid was noted to contain a goiter hemorrhage with no signs of neoplastic degeneration on pathology. Conclusions: Pregnancy is a known hormonal stressor that routinely increases the size of the thyroid and also predisposes patients to goiter formation. In rare cases, thyroid goiters may be predisposed to hemorrhage, causing airway obstruction and necessitating urgent surgical intervention.

Sharks possess a variety of pathogenic bacteria in their oral cavity that may potentially be transferred into humans during a bite. The aim of the presented study focused on the identification of the bacteria present in the mouths of live blacktip sharks, Carcharhinus limbatus, and the extent that these bacteria possess multi-drug resistance. Swabs were taken from the oral cavity of nineteen live blacktip sharks, which were subsequently released. The average fork length was 146 cm (±11), suggesting the blacktip sharks were mature adults at least 8 years old. All swabs underwent standard microbiological work-up with identification of organisms and reporting of antibiotic susceptibilities using an automated microbiology system. The oral samples revealed an average of 2.72 (±1.4) bacterial isolates per shark. Gram-negative bacteria, making up 61% of all bacterial isolates, were significantly (p