Medicine in Ancient Egypt. "World's first prosthesis. Artificial toe found with an ancient Egyptian mummy"

Medicine in Ancient Egypt

Medicine in Ancient Egypt

 of the profession of medicine are buried far back before the dawn of history. Nearly as old as mankind itself, practice of medical procedures in some from has paralleled man’s development. In not a few instances, the quality or lack of medical service has profoundly influenced the quality of medical service has profoundly influenced the course of civilizations. Throughout the dawning millennia and much of their recorded history, medicine was intimately associated with the magico-religious practices of various peoples groping for the light knowledge and a better way of life.

The most ancient records presently known indicate the existence of two centers of civilizations having nearly equal development in two of the world’s great river systems: in Mesopotamia, between the Tigris and the Euphrates; and in the Nile valley of northeastern Africa. Organized peoples, enjoying the natural habitational advantages of these areas, were flourishing 6,000 years ago.

Methods of recording events began some ten centuries later, about 3000 B.C., and from that point on, history has for its base a series of factual foundations. However, when recorded history dawned, medicine was already a well-developed profession, and its practitioners had a heritage of experience, knowledge and beliefs handed down from a long line of predecessors by precept and word –of-mouth through countless centuries.

Egypt first became an organized nation about 3000 B.C. Medical interest centers upon a period in the Third Dynasty (2980-2900 B.C.) When Egypt had an ambitious Pharaoh named Zoser; and Zoser, in turn, had for his chief counselor and minister a brilliant noble named Imhotep (whose name means “he who cometh in peace”). Imhotep is said to have constructed the famous step pyramid of Sakkarah, near Memphis, for Pharaoh Zoser. A versatile man, Imhotep seems to have been a priest, a magician, and a poet. But in the Egyptian writings of the Greco-Roman period (third century, B.C.) Imhotep is represented as a physician, is assigned the role of god of medicine in Egypt. The Greeks identified him with their Asclepios, to whom was attributed a similar regard. In this later period, temples were erected to Imhotep in which patients looked for and supposedly found relief in their sleep.

There is a close association in Egyptian medicine between religion and magic. Egyptian physicians used many drugs, but thought their effects primarily magical. The papyri (so Called because they were written on sheets prepared from the papyrus plant) dealing exclusively with medicine abound with magic formulas and prayers. “In some cases in which human help seemed to be impossible,” observes Hermann Ranke, a last attempt was made to get help from a supernatural source. .” a practice not imcompatible with that of the religious-minded physician of today who through prayer seeks aid and guidance. The gods of the Egyptians were no less real to them than is our deity to us.

Physicians of ancient Egypt were probably trained in the temples, as were the priest- magicians and sorcerers. However, they formed a distinct profession, organized in a rigid hierarchy with court physicians at the top. Egyptian medicine was subdivided into many specialties. A proctologist had the poetic name of “shepherd of the anus,” and was much in demand in view of prevalent pathogenic theories. Egyptian specialization seems to have been hangover of primitive conditions rather than a precursor of modern specialization.

Medicine as practiced by the ancient Egyptians was not primitive, however. Just as they had transcended primitive levels in statecraft, agriculture, technology and especially architecture and art, so did the Egyptians also reach higher levels in medicine. Some medical papyri are predominantly religious, but others are predominantly empiric rational. Strangely enough, those recording the more rational observations stem from the earliest periods (1600-1500 B.C.). Among these are the Edwin Smith Papyrus and the Ebers papyrus. The first was intended primarily for the use of a surgeon; the latter is a collection of recipes for the physician. Each of these documents, though ancient in its own right, appears by language and explanations to reflect traditions much older. Says Ranke of the Smith papyrus: “That the bulk of the main text goes back to the Old Kingdom (about 2500 B.C.) is shown by a great number of glosses (explanatory notes) added to the text of some of the cases, which explains words that in the course of time had become obsolete.” Breasted dates the Smith papyrus in the seventeenth century B.C., but states that it is a copy of a document at least one thousand years older.

Dealing primarily with wounds, the Edwin Smith papyrus is admired for the diagnostic acumen exhibited in the case histories detailed, where symptoms such as feeble pulse (2500 years before reference to the pulse appears in Greek medical treatises), palsy, and deafness are all recorded and referred to as due to one common cause- a head wound. In addition to many surgical conditions, a great number of recognizable internal afflictions are reported in the papyri, such as worms, eye diseases, diabetes, rheumatism and schistosomiasis. The ancient existence of some of these conditions is confirmed by paleopathology (the examination of bones and tissues of mummies for evidence of disease); and, unfortunately, those afflictions are still prevalent in Egypt.

The papyri prescribe many rational methods of treatment, such as diet, physiotherapy and drugs. Many of the drugs named undoubtedly were worthless, but some, such as tannic acid, turpentine, gentian, senna, and lead, and copper salts, are still used in medical practice. Castor oil, used externally and internally, was a great favorite with the doctors of Egypt. The style used in prescription writing today is pretty much the same as then.

The cases of the Edwin Smith papyrus are not only systematically constructed; each within itself, but their arrangement throughout is a systematic one. First comes a superscription, which briefly gives the name of the illness. This is followed by a careful description, which always begins with the words, “ If you examine a man who…” has this or that illness. Then comes a diagnosis that always begins with the words, “You should say” he suffered from this or that ailment. This diagnosis always ens with the words: “An ailment which…’ and then one of three possibilities follows. The Surgeon may say: “An ailment which I shall treat, “or, “An ailment which I shall combat,” or, “An ailment which I will not treat.” (The latter discrimination was practiced by some physicians in almost all periods and was regarded as ethical up to the eighteenth century.) Except in entirely hopeless cases, there followed a method of treatment, beginning with the words, You must do…” this or that. Then the healing substances are given.

Of the 48 surgical dissertations in the Smith papyrus, Case 7 is of particular interest. According to Breasted’s translation, it reads, in part;
“If thou examinest a man having a gaping wound in his head, penetrating to the bone, and perforating the sutures of his skull, thou should palpate his wound, although he shudders exceedingly. Thou shouldst cause him to lift his face; if it is painful for him to open his mouth, and heart beats feebly; if thou observe his spittle hanging at his two lips and not falling off, while he discharges blood from both his nostrils and from both his ears; he suffers with stiffness in his neck, and is unable to look at his two shoulders and his breast, thou shouldst say regarding him: {here the findings are restated}. An ailment with which I will contend.”

Directions for treatment follow:

“Now as soon as thou findest that the cord of that man’s mandible, his jaw, is contracted, thou shouldst have made for him something hot, until he is comfortable, so that his mouth opens. Thou shouldst bind it with grease, honey, and lint, until thou knowst that he has reached a decisive point.”

Two other possible examinations are outlined- the second, in which;
“the flesh of that man has developed fever… his countenance is clammy, the ligaments of his neck tense, his face is ruddy, and… the odor of the chest of his head [crown] is like the urine of sheep, his mouth is bound…” This, the ancient author admonishes, is “An ailment not to be treated.”
“If, however, thou findest that that man has become pale and already has shown exhaustion… Thou shouldst have made for him a wooden brace padded with linen and put into his mouth. Thou shouldst have made for him a draught of the… fruit [probably a nutritious fruit or grain]. His treatment is sitting, placed between two supports of brick, until thou knowest he has reached a decisive point.’
This early physician evidently recognized that if tetanus had invaded the wound, there was little he could do; but until he was certain, he would try to improve the patient’s condition.

Egyptian physicians were highly respected all over the ancient world for thousands of years. Homer regarded them as the best in his time. Egyptian physicians were called to the courts of Persian emperors and other Eastern potentates; and only in the sixth century B.C. were they replaced by Greek physicians. Beyond the psychotherapeutic values of magic and religion, Egyptian medical men made solid advances in observation and rational treatment. Their contributions are worthy of a place beside other accomplishments of this great ancient civilization. The dominant position occupied by Egyptian medicine for 2,500 years seems fully justified.

THE PICTURE

A moment in the life of an Egyptian physician of the Eighteenth Dynasty (1500-1400 B.C.) is captured in this painting. The physician is confronted with a patient having symptoms paralleling those cited in the third diagnosis of the seventh case history recorded in the Edwin Smith papyrus. Most of the elements of ancient Egyptian medicine are here: The physician, clothed in clean white linen and a wig, as becomes the dignity of his status. The patient, likely a member of a noble household, supported by a “brick chair.” Treatment is proceeding under the sure, sympathetic hands of the physician in accordance with the course prescribed in the scroll held in the hands of an assistant. Magico-religious rites are being observed by priests trained in this adjunctive specialty. The best care that the science and knowledge of the day can provide is focused on the patient. 

World's first prosthesis.
Artificial toe found with an ancient Egyptian mummy.

AVISO IMPORTANTE A NUESTROS USUARIOS

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Es pues, la propia comunidad de usuarios quien certifica la fiabilidad de cada uno de los elementos de información, a través de una tarea continua de refinamiento y valoración por parte de los usuarios.

Si usted encuentra información que considera erronea, le invitamos a hacer efectivo su registro para poder avisar al resto de usuarios y contribuir a la mejora de dicha información.

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Tactical Trauma 2019 TacT19 October 8-9 Sundsvall. Sweden

 Tactical Trauma 2019 TacT19 October 8-9 Sundsvall. Sweden

http://www.tacticaltrauma.se/

It’s a great honour to invite you to the second TacticalTrauma conference,

October 8-9, 2019!

This is an international conference on pre-hospital trauma and critical care. With a tactical twist.

Our programme is rich and varied with state of the art lectures from world class speakers and we bring together all organisations working with pre-hospital trauma in a tactical/hostile environment. Physicians, EMS, Police anti-terror units, Military, Fire and Rescue service etc.

TacticalTrauma17 was a great success, sold out 4 months ahead, 100+ on the waiting list. When we are back in 2019 we will keep the same size but make it even better. More international top speakers, workshops and two masterclass sessions. On day one there will be Trauma masterclass. On day two there will be a Tactical focus session giving a broad overview on everything from K9 care to modern day terrorism.

For our police and SOF participants there will be some dedicated sessions like in 2017.

It is our hope that we will spark discussions and networking between individuals, organisations and countries. You will have ample possibilities to do this with international colleagues, industry and faculty during coffee breaks, lunch and social events.

If you didn´t participate in #TacT17 you can get a grip of the conference by listening to the podcasts on EMS Nation (Youtube channel and podcast)

The conference has been made possible thanks to a donation from The Swedish Carnegie Hero Fund.

To follow us on Twitter: @TacTrauma

TacticalTrauma19 is arranged by the Emergency Clinic/EMS, County Council of Västernorrland together with the Police Tactical Unit, Västernorrland.

This is an exclusive event with a limited amount of tickets.

Please make sure you register as soon as possible. In 2017 we sold out 4 months ahead.

SPEAKERS



TacT19 in Sweden

The Trip Report: Pediatric Education in EMS by EMSWORLD.com

The Trip Report: Pediatric Education in EMS by EMSWORLD.com

Grupo en TELEGRAM Sociedad Iberoamericana de Emergencias https://t.me/joinchat/FpTSAEHYjNLkNbq9204IzA

Download in PDF for free

The Trip Report: Pediatric Education in EMS

By Antonio R. Fernandez, PhD, NRP, FAHA Mar 24, 2017 

Turning Research Into Practice: Dr. Seth Brown and his coauthors recently published a manuscript examining pediatric education for EMS providers. This is a great opportunity to discuss a study design not often utilized in EMS or medical literature: the qualitative study. www.emsworld.com/12319193

REVIEWED THIS MONTH: Brown SA, Hayden TC, Randell KA, Rappaport L, Stevenson MD, Kim IK. Improving Pediatric Education for Emergency Medical Services Providers: A Qualitative Study. Prehosp Disaster Med, 2017 Feb; 32(1): 20–26.

This month is dedicated to educational research. Dr. Seth Brown and his coauthors recently published a manuscript examining pediatric education for EMS providers. This is a great opportunity to discuss a study design not often utilized in EMS or medical literature: the qualitative study.

Most research published in EMS and other medical literature involves quantitative studies. Quantitative studies rely on numbers to examine statistical significance. Qualitative studies don't rely on calculations; they gather information from unstructured interviews, focus groups, diaries and other methods. The information is explained, contextualized and often grouped into categories. Qualitative studies often generate hypotheses that can be tested in future quantitative studies.

Examining Education

As we are all well aware, pediatric patients make up a very small number of 9-1-1 calls. While it's fantastic that children aren't often sick or injured enough to account for a large percentage of EMS calls, this does leave us at a disadvantage when we're asked to care for a child. Many EMS providers just don't have the field experience, which makes our initial and continuing education on pediatric care that much more important.

With that in mind, the authors of this study utilized focus groups to understand how EMS providers in Kentucky felt about deficits in EMS pediatric education. They also sought to come up with suggestions on ways to improve pediatric education and training. They worked with the state EMS system to identify focus group participants. Training officers were contacted by the study team and asked to invite potential participants from their agency.

The authors chose to have separate focus groups for EMS providers who worked in urban, suburban and rural areas. They also held separate focus groups for administrative and nonadministrative personnel. We all know there are urban and rural differences, and a paramedic might not be so open to identifying deficits (in other words, criticizing) the con ed provided by their agency with their boss in the room.

They had a total of six focus groups (one for administrators and one for field providers in each of the three community types). They limited the focus groups to a maximum of 10 participants. This was also a good idea; it can get very difficult to moderate a focus group with too many participants. The focus groups lasted a total of 90 minutes and were audio-recorded and professionally transcribed.

Now, you might be thinking a maximum of 10 participants each in six focus groups would mean the study drew conclusions from just 60 people. In fact, the total number of participants was 42. Yes, compared to most EMS literature we will review here, that is a very small number. You may remember a couple months ago we reviewed a study with over 2,000 cases. Qualitative studies don't need to rely on large numbers. Actually, they typically never have a study population that is very large. This study design allows you to get a lot of in-depth information from a small number of participants.

One really interesting part of this study was that they used a "professional moderator." This was a great way to prevent any bias the study team may have from their familiarity with EMS pediatric education from altering the opinions of the focus group participants. This often adds cost to the study.

Analyzing the Data

Now we'll discuss the most difficult part of qualitative research, data analysis. In quantitative research, when you are ready to analyze your data, what is probably the most difficult part of the study (obtaining enough data to analyze) is over. In qualitative research, you have to review every focus group meeting multiple times and read notes and transcripts to come up with consistent messages, themes and categories. Luckily this is a science, so there are tested methods and strategies to analyze qualitative data. We don't have enough space to review each of these here, but an overly simplified explanation is that the authors listened to every audio recording and read every transcript multiple times until they could identify overarching categories. They drilled down on these categories to combine ideas and thoughts that were very similar. Finally they took some steps to make sure that they all agreed on the results.

When all that work was done, they were left with four major themes for deficits in pediatric EMS education: 1) suboptimal previous pediatric training and training gaps in continuing education; 2) opportunities for improved interactions with ED staff, including case-based feedback on patient care; 3) barriers to optimal pediatric prehospital care; and 4) proposed pediatric training improvements.

Under the theme of suboptimal previous pediatric training and training gaps in continuing education, the authors found PowerPoint may be overused in pediatric education, and participants reported that educators are often not very familiar with the material or how care is provided to peds in the prehospital environment.

The theme of opportunities for improved interactions with ED staff focused largely on the desire of EMS providers to know the outcomes of the patients they cared for and the difficulty with obtaining that information from the ED.

The barriers to optimal pediatric prehospital care simply restated that EMS providers don't see children very often, and when they did the focus group participants didn't feel like they were provided enough guidance on how to care for complicated patient scenarios.

Finally, proposed pediatric training improvements included increasing the frequency of training, increasing hands-on time with pediatric patients, more shadowing and observation of pediatric emergency care providers, and increasing specific content areas of medication dose calculations and administrations, IV access, airway management and resuscitation.

From these four themes the authors came up with five hypotheses they felt could improve pediatric patient care:

• More online training may help fulfill training needs;
• Obtaining more feedback in the ED;
• Implementing a more standardized pediatric training;
• Increasing training in airway maintenance, IV access, drug calculations and medication administration;
• Targeted education on special-needs and medically fragile children.

Interestingly, the authors also stated that this study was the first to identify and publish that there are concerns regarding patient handoffs from EMS providers to ED staff. This is an unfortunate error and highlights the importance of a thorough literature review. Patient handoffs have been addressed in medical literature prior to the publication of this study. The American College of Emergency Physicians has discussed the importance of an appropriate patient handoff, and we even reviewed a paper on patient handoffs in this column last month. It is possible the authors' claim was true in 2013 when the focus groups took place, but in 2017, when this paper was published, this study is not the first to discuss the importance of patient handoffs.

Finally, the authors stated that they used a professional moderator and a professional to transcribe the meetings. Unless the group of MDs and PhDs that authored this study have had this professional training, they had to pay someone. Since they specifically state these services were used to reduce bias, it's unlikely the authors did this work. They do not list a funding source for the study. Specifying a funding source, if one was used, is extremely important to put these results into context. If this study was funded by a company that produces standardized online pediatric training, we might think differently about its conclusions. I am not suggesting the authors are trying to hide anything, but I am suggesting this information should have been included in the manuscript.

Antonio R. Fernandez, PhD, NRP, FAHA, is the research director at the EMS Performance Improvement Center and an assistant professor in the Department of Emergency Medicine at the University of North Carolina–Chapel Hill. He has been a nationally certified paramedic since 2005 and completed the EMS Research Fellowship at the National Registry of Emergency Medical Technicians.

Damage Control Resuscitation Principles Adapted for EMS Civilian Trauma Sat, Apr 1, 2017 By William Selde, MD

ourniquets are indicated when direct pressure is unable to establish bleeding control

Original post http://www.jems.com/articles/print/volume-42/issue-4/features/damage-control-resuscitation-principles-adapted-for-ems-civilian-trauma.html

You and your partner are dispatched to the scene of a rural motor vehicle collision. After a 35-minute response, you arrive on scene to find a single patient who was involved in a vehicle rollover on a state highway. The driver is unrestrained and still in the vehicle.

The vehicle shows a large amount of external damage. The patient is awake and alert but complaining of abdominal pain. Volunteer fire department personnel have placed him in a C-collar prior to your arrival and are extricating him on a long backboard to ease movement from the roadside ditch to your gurney.

As the patient is removed from the backboard, you begin your assessment. You find a 19-year-old male who shows no signs of serious head trauma and reports the accident occurred when he "swerved to miss a bunny rabbit."

The young man's chest is clear to auscultation. His chest wall is stable but mildly tender to palpitation. His heart sounds tachycardic. He has a strong carotid pulse.

As you finish your primary assessment, your partner reports vitals: heart rate of 115, blood pressure 100/65 mmHg, pulse oximeter 98%, temperature 37 degrees C. Your partner sets the blood pressure cuff to cycle every five minutes and establishes IV access.

Upon physical examination you find the patient's abdomen is rigid with marked tenderness in the left upper quadrant. His extremities show abrasions to his left upper leg and left forearm. No other apparent injury is noted.

The patient moves all four extremities on command. His pelvis is stable. He denies any loss of consciousness and reports that he thinks he hit the steering wheel with his abdomen. He takes no medications daily. He has no allergies. He denies any drug or alcohol use.

Damage Control

Trauma remains a major cause of death and disability globally.^1,2 Damage control resuscitation is a strategy that focuses on attempting to maintain or restore homeostasis intrauma patients.

The name "damage control" references the naval tactics employed to keep a damaged ship as combat-capable as possible until definite repair can take place. The concept goes hand in hand with damage control surgery. However, for prehospital care, surgery is clearly beyond the scope of practice and won't be discussed here.

First described in the late 1970s and early 1980s, damage control resuscitation has continued to evolve and is primarily focused on mitigating the life threats of trauma.³

The main threats concentrated on in damage control resuscitation are acidosis, coagulopathy and hypothermia. Ideally, these pathologies are all addressed in a simultaneous and balanced manner. These three abnormalities form a forward feedback loop that leads to progressive worsening of a patient's hemodynamic status and will eventually lead to death.

This instability is due to the fact that the human body is designed to function within a very narrow set of physiologic parameters. The enzymes that dictate cellular metabolism function best at a pH of 7.4 and temperature of 37 degrees C.

These enzymes allow the chemical reactions the body relies upon to occur at a lower energy input than would be chemically required without them. Deprived of the actions of these enzymes, the body's ability to perform basic functions is severely impaired.

Lactic acid formation is a result of tissue hypoxia. Tissue hypoxia can occur because not enough blood is getting to the tissues (hypoprofusion) or the blood that is being supplied is very poorly oxygenated.

The end result at the cellular level is a switch from oxidative phosphorylation to anaerobic metabolism yielding lactic acid as a byproduct. Whatever the cause, lactic acid lowers the pH of the body when it exceeds the body's physiologic buffering capacity.

Coagulopathy occurs when the enzymes that cause blood to clot are unable to function, or the body is out of clotting factors. Bleeding from trauma causes consumption of clotting factors.

Additionally, infusion of fluid deficient of clotting factors exacerbates this by causing dilution. A low pH due to lactic acidosis or a low body temperature also causes coagulopathy. Hypothermia results when the body loses more heat to the environment than it is able to produce.⁴

Metabolism is a large source of body heat production. As the body's temperature drops, all enzymes become less efficient.³ This results in worsening coagulopathy, and decreased metabolism, including decreased lactic acid breakdown. The decrease in metabolism not only results in impaired lactic acid clearance but impaired ability to produce heat. This worsens coagulopathy and hypothermia.

Worsening coagulopathy leads to continued bleeding, worsening tissue hypoprofusion and lactic acid production. Thus, the forward feedback cycle is perpetuated. (See Figure 1, p. 36.)

Figure 1: The forward feedback cycle following traumatic injury

Patients in Need

Identifying which patients are in need of damage control resuscitation is similar to identifying which patients need the highest level of trauma care. Since prehospital care is often limited by resources and time (vs. in-hospital care), historic and physiologic findings are most helpful to identify these patients. These objective findings can be relatively quick and easy to identify on scene.

Anatomic parameters for damage control resuscitation consideration include: injury severity score > 36, penetrating abdominal or chest injuries, unstable pelvic fracture, long bone fracture with head injury, truncal hemorrhage or amputation.3

Physiologic parameters include: weak or absent radial pulse, core body temperature < 35 degrees C, systolic blood pressure < 100 mmHg, and heart rate > 100.3

These criteria are similar to, although not quite the same as, the guidelines for field triage of injured patients from the American
College of Surgeons Committee on Trauma (ACS-COT). The ACS-COT physiologic guideline include Glasgow coma scale < 13, systolic blood pressure < 90, respiratory rate < 10 or > 29 breaths per minute (< 20 if under age 1 year), or need for respiratory support.⁵

The ACS-COT anatomic guidelines include all penetrating injuries to the head, neck, torso and extremities proximal to the elbow or knee; chest wall instability or deformity; two or more proximal long bone fractures; crushed, degloved, mangled or pulseless extremity; amputation proximal to the wrist or ankle; pelvic fracture; open or depressed skull fracture; or paralysis.⁵

^{Damage control resuscitation is a strategy that
focuses on attempting to maintain or restore
homeostasis in trauma patients. Photo Andrew Klein}

Hemorrhage Control

The mainstay of breaking the pathophysiologic cycle is to achieve hemorrhage control. In circumstances where only definitive surgery is capable of stopping bleeding, getting the patient to the operating room in a timely fashion is of the utmost importance. There are, however, tools available to EMS that can temporize bleeding until an operating room can be reached.

The first-line treatment for bleeding is direct pressure. Direct pressure results in superior measurements of wound pressure when compared to standard and elastic dressings. One study showed average pressures of 180 mmHg with direct pressure, 88 mmHg with elastic bandages, and 33 mmHg with standard bandages.6

The amount of pressure applied is important because in order to stop the bleeding, the pressure must exceed the blood pressure at the wound. Although it's labor intensive, direct pressure achieves higher pressures than either elastic or standard bandages.

Tourniquets are indicated when direct pressure is unable to establish bleeding control.⁷ The tourniquet has been around in various iterations for hundreds of years. When indicated, the tourniquet should be applied as soon as possible. There's a decrease in mortality when tourniquets are applied in the field vs. the ED.⁸ Once applied, the tourniquet should be left on until definitive care is reached.

Another option for bleeding that's not controllable with direct pressure is hemostatic dressings. Hemostatic dressings generally have high success rates for controlling bleeding that's resistant to direct pressure.⁹

These dressings are broadly divided into three categories: intrinsic pathway activators, factor concentrators and mucoadhesive agents.

Intrinsic pathway activators directly signal the blood to clot. Examples of intrinsic pathway activators include kaolin and smectite.

Factor concentrators work by absorbing the liquid component of the blood, leaving concentrated clotting factors to form a clot. An example of factor concentrators includes mucopolysaccharide hemispheres.

Mucoadhesive agents work by forming an electron bond to cell walls. Examples of mucoadhesive agents include chitosan-
containing compounds.

Pelvic and femur fractures can result in significant bleeding.^10,11 The bleeding associated with unstable pelvic fractures is usually from the sacral venous plexus.¹² It can often be temporized with some sort of pelvic binder, be it improvised or commercial.^13,14

Traction splints may decrease the bleeding associated with femur fractures. No good modern data exists regarding traction splints; however, anecdotal evidence from World War I shows a significant decrease in mortality for isolated femur fracture after instating a traction splinting program.¹⁵ Therefore, splinting is important to keep in mind and accomplish as soon as possible after other serious sources of bleeding have been addressed.

Fluid Administration

Appropriate fluid administration might help to maintain homeostasis. Inappropriate fluid administration will do just the opposite.¹⁶

In penetrating trauma to the torso, in particular, research shows that withholding isotonic IV fluid had a mortality benefit.¹⁷ This data came from an urban EMS system where transport times were presumed to be relatively short. Only patients with a systolic blood pressure of 90 mmHg or less were included. This would seem to suggest that there may be a role for restrictive isotonic fluid administration.

There's additional data to support this and even extrapolate it to blunt trauma. Large data from a national trauma data bank suggest that IV fluid administration is associated with increased mortality for all types of trauma.¹⁸ Although the absolute difference in the results is low (0.3%), it's statically significant given the large study size of 776,000 patients. There's of course some disagreement in the literature with some studies showing no harm from IV fluid.¹⁹

ED data from a large Level 1 trauma center showed an increase in mortality associated with IV fluid volumes of greater than 1.5 L but no increase in mortality with 1 L of fluid or less.²⁰

It's postulated that the benefit may come from decreased dilatational coagulopathy and hemostatic maintenance.²⁰ There appears to be no benefit from using hypertonic saline compared to normal saline in the prehospital setting.²¹ Although there's no perfect prehospital study, these studies did attempt to control for severity of injury and other confounding factors. Current evidence, however, doesn't support the strategy of allowing a low blood pressure and restricting fluid in patients with head injuries.²²

Hypotensive head trauma patients have increased mortality compared to patients resuscitated to a normal blood pressure. The takeaway message is that the minimum amount of isotonic fluid needed to maintain mental status or mean arterial pressure of 65 mmHg is probably the best strategy for patients without significant head injury.^3,23

Blood & Plasma Transfusion

Transfusion of blood products is a potentially lifesaving intervention for patients with severe trauma. The ideal initial ratio for the massive transfusion of blood products is generally accepted to be one unit of fresh frozen plasma to one unit of platelets to one unit of packed red blood cells (PRBCs) (1:1:1).²⁴

Recent research has looked at a lower ratio of platelets and plasma to packed cells 1:1:2. It showed that though the absolute all-cause mortality rate was lower in the 1:1:1 group, there was no statistical difference in mortality at 24 hours or 30 days. Notably, the 1:1:1 group did have statistically significant higher rates of hemostasis and lower rates of death due to exsanguination at 24 hours. Additionally, the complication rate was the same for both groups.²⁵

A study of trauma patients transported by a helicopter EMS system that carried blood found that early transfusion in trauma patients with hemorrhagic shock results in decreased mortality.²⁶

There was a correlation between shorter time to transfusion and survival for patients who received blood within one hour of arrival to the ED. This benefit wasn't found for all patients who received blood in the first 24 hours. This suggests a confounding factor: that this subset of patients was different than the patients who were not transfused with in the first hour of ED admission.²⁶

Early transfusion with blood products is more beneficial than high volume isotonic fluid.^3,27

Another component available to some EMS agencies is plasma. Plasma is the liquid component of the blood and contains many proteins including clotting factors. Although the exact mechanisms are unknown, plasma does decrease the damage to the lining of the blood vessels, the endothelium. This results in less fluid leaking out into the tissues.

Early plasma transfusion appears to have a favorable impact on mortality in trauma patients and is an integral part of balanced transfusion as noted above. Prehospital trauma trials investigating its efficacy are ongoing, and recent changes in logistical considerations may make plasma more feasible for prehospital use in the near future.²⁸

^{Transfusion of blood products is a potentially lifesaving intervention for
patients with severe trauma. Photo courtesy North Memorial Ambulance Service}

Pharmacologic Treatments

Pharmacologic treatments that may have a role in treating trauma-induced coagulopathy include: prothrombin complex concentrate (PCC), cryopricpate, calcium and tranexamic acid (TXA).

PCC is used to reverse pharmaceutical anticoagulation. It's a mix of vitamin K-dependent clotting factors and isn't typically used in the prehospital setting.

Cryopricpiate contains clotting factors VIII and XIII in addition to fibrinogen and von Willebrand factor. It isn't generally used in prehospital care in the United States.

Calcium is essential in the clotting cascade for the conversion of factor X to factor Xa and for the conversion of prothrombin to thrombin. Both of these reactions are critical for formation of a blood clot. Low calcium is a predictor of trauma mortality.²⁹

Calcium is chelated, or captured by citrate. Citrate is used to keep donated blood from clotting. Thus, when PRBCs are transfused so is some citrate. This leads to calcium chelation and lowering of serum calcium.

In one study's sample of 156 massive transfusion patients, 97% developed hypocalcemia. Those who developed severe hypocalcemia had significantly lower pH, lower platelets, higher lactic acid and higher mortality (49% vs 24%).²⁹

Another study found that 55% of major trauma patients arrived to the ED with hypocalcemia and 89% developed hypocalcemia after receiving one unit of blood. The authors concluded that, "With increasing early blood product use, trauma victims being at risk of hypocalcemia and receiving any amount of blood product further worsening this state, prompt recognition of hypocalcaemia and early targeted therapy is needed from arrival." ³⁰

Additionally, calcium helps to increase myocardial contractility, countering the effect of hyperkalemia caused by acidosis. This results in increased blood pressure. It would seem reasonable for prehospital providers to begin replacing calcium after one unit of blood is transfused, or in anticipation of massive transfusion.

TXA is FDA approved for the treatment and prevention of dental bleeding in hemophilia and heavy menstrual bleeding and has seen "off-label" use to reduce blood loss during cardiac and orthopedic surgery as well as for trauma patients. TXA appears to stabilize blood clots by competitively binding to the lysine binding site on plasminogen and preventing its conversion to plasmin. This stops clot breakdown and is thought to result in less bleeding. As there's less clot turnover, TXA is theorized to reduce depletion of clotting factors and reduce consumptive coagulopathy. Since TXA is a lysine analog, it may have other physiologic effects that are not fully understood.

There's a large amount of data showing that TXA reduces bleeding associated with cardiac and orthopedic surgery. In a study of over 800,000 orthopedic cases that TXA reduce the needs for transfusion (7.7% vs 20.1%) and had no increase in complications.³¹ TXA is also used routinely in pediatric cardiac surgery, though it's infrequently used in pediatric trauma.³² In a small trial of 776 trauma patients, TXA appeared to significantly reduce pediatric trauma mortality.³³

Following the publication of two seminal studies, MATTERS and CRASH-2, TXA was received enthusiastically in the U.S with multiple prehospital systems adding it to their formulary.²⁷ This has resulted in significant controversy, largely due to the fact that the above studies aren't the most robust in design, resulting in concern about the true benefits of TXA in trauma.

The role of TXA in head trauma is unclear and currently being studied. Although there are multiple ongoing, more robustly designed prehospital studies, in the current literature it does appear that TXA may offer a benefit to trauma patients receiving massive transfusion, and regardless of benefit, causes no increase in complications.²⁷ Since there appears to be a time-dependent component to the benefit of TXA, it would seem reasonable to continue TXA prehospital use in patients who meet transfusion criteria.^3,27

Hypothermia

Prehospital awareness of hypothermia is important for its management. After all, the mechanism by which patients become hypothermic is due to the movement of heat from hot (e.g., the patient) to cold (e.g., the environment).

If patients are insulated from heat loss, they'll be better able to maintain their temperature. This becomes particularly important when the patient has impaired heat production due to acidosis-the forward feedback cycle can be hard to break once it starts. An additional intervention is the use of hot packs or heated wraps, but extreme care must be taken not to cause burns.

Conclusion

The next blood pressure reading on the patient is 87/62 mmHg, and his heart rate is 120. He states that he "feels a little dizzy." Your partner starts a 250 mL bolus of normal saline.

Dispatch states that the helicopter that was activated and launched will arrive at the off-hospital helipad a few minutes before you'd arrive at the critical access hospital, so you make the decision, following local protocol, to bypass that hospital.

Despite the infusion of normal saline, the patient's blood pressure is still 88/60 mmHg, but his heart rate is 113 and he feels less dizzy. Your partner decreases the rate to keep the line open.

On arrival, the helicopter flight crew evaluates the patient. His heart rate is again in the 120 range. They start a second large-bore IV and begin to transfuse PRBCs and initiate transport to the nearest trauma center.

After transiently responding to the PRBCs, the patient receives 1 gram of calcium chloride, 1 gram of TXA and 1 unit of plasma inflight. He survives because of the joint efforts of the on scene responders and flight crew as a result of clear, well-defined trauma protocols, advanced hemorrhage control care, and rapid transport to the appropriate trauma center.

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By

William Selde, MD

William Selde, MD, is a board certified emergency medicine physician at the Wyoming Medical Center and a graduate of the EMS fellowship at the University of New Mexico. He can be reached at william.selde@wyomingmedicalcenter.org,