The use of direct oral anticoagulants (DOACs) such as rivaroxaban (Xarelto) is increasingly common. However, therapies for reversing anticoagulation in the event of hemorrhage are limited. This study investigates the ability of hemostatic agents to improve the coagulation of rivaroxaban-anticoagulated blood, as measured by rotational thromboelastometry (ROTEM).

If a chitosan-based hemostatic agent (Celox), which works independently of the clotting cascade, is applied to rivaroxaban-anticoagulated blood, it should improve coagulation by decreasing clotting time (CT), decreasing clot formation time (CFT), and increasing maximum clot firmness (MCF). If a kaolin-based hemostatic agent (QuikClot Combat Gauze), which works primarily by augmenting the clotting cascade upstream of factor Xa (FXa), is applied to rivaroxaban-anticoagulated blood, it will not be effective at improving coagulation.

Patients (age >18 years; non-pregnant) on rivaroxaban, presenting to the emergency department (ED) at two large, university-based medical centers, were recruited. Subjects (n=8) had blood drawn and analyzed using ROTEM with and without the presence of a kaolin-based and a chitosan-based hemostatic agent. The percentage of patients whose ROTEM parameters responded to the hemostatic agent and percent changes in coagulation parameters were calculated.

Data points analyzed included: CT, CFT, and MCF. Of the samples treated with a kaolin-based hemostatic agent, seven (87.5%) showed reductions in CT, eight (100.0%) showed reductions in CFT, and six (75.0%) showed increases in MCF. The average percent change in CT, CFT, and MCF for all patients was 32.5% (Standard Deviation [SD]: 286; Range:-75.3 to 740.7%); -66.0% (SD:14.4; Range: -91.4 to -44.1%); and 4.70% (SD: 6.10; Range: -4.8 to 15.1%), respectively. The corresponding median percent changes were -68.1%, -64.0%, and 5.2%. Of samples treated with a chitosan-based agent, six (75.0%) showed reductions in CT, three (37.5%) showed reductions in CFT, and five (62.5%) showed increases in MCF. The average percent changes for CT, CFT, and MCF for all patients were 165.0% (SD: 629; Range:-96.9 to 1718.5%); 139.0% (SD: 174; Range: -83.3 to 348.0%); and -8.38% (SD: 32.7; Range:-88.7 to 10.4%), respectively. The corresponding median percent changes were -53.7%, 141.8%, and 3.0%.

Rotational thromboelastometry detects changes in coagulation parameters caused by hemostatics applied to rivaroxaban-anticoagulated blood. These changes trended in the direction towards improved coagulability, suggesting that kaolin-based and chitosan-based hemostatics may be effective at improving coagulation in these patients.

BarJ, DavidA, KhaderT, MulcareM, TedeschiC. Assessing Coagulation by Rotational Thromboelastometry (ROTEM) in Rivaroxaban-Anticoagulated Blood Using Hemostatic Agents. Prehosp Disaster Med. 2017;32(5):580–587.

A model prepared by National Civil Defense (INDECI; Lima, Peru) estimated that an earthquake with an intensity of 8.0 Mw in front of the central coast of Peru would result in 51,019 deaths and 686,105 injured in districts of Metropolitan Lima and Callao. Using this information as a base, a study was designed to determine the characteristics of the demand for treatment in public hospitals and to estimate gaps in care in the hours immediately after such an event.

A probabilistic model was designed that included the following variables: demand for hospital care; time of arrival at the hospitals; type of medical treatment; reason for hospital admission; and the need for specialized care like hemodialysis, blood transfusions, and surgical procedures. The values for these variables were obtained through a literature search of the databases of the MEDLINE medical bibliography, the Cochrane and SciELO libraries, and Google Scholar for information on earthquakes over the last 30 years of over magnitude 6.0 on the moment magnitude scale.

If a high-magnitude earthquake were to occur in Lima, it was estimated that between 23,328 and 178,387 injured would go to hospitals, of which between 4,666 and 121,303 would require inpatient care, while between 18,662 and 57,084 could be treated as outpatients. It was estimated that there would be an average of 8,768 cases of crush syndrome and 54,217 cases of other health problems. Enough blood would be required for 8,761 wounded in the first 24 hours. Furthermore, it was expected that there would be a deficit of hospital beds and operating theaters due to the high demand.

Sudden and violent disasters, such as earthquakes, represent significant challenges for health systems and services. This study shows the deficit of preparation and capacity to respond to a possible high-magnitude earthquake. The study also showed there are not enough resources to face mega-disasters, especially in large cities.

BambarénC, UyenA, RodriguezM. Estimation of the Demand for Hospital Care After a Possible High-Magnitude Earthquake in the City of Lima, Peru. Prehosp Disaster Med. 2017;32(1):106–111.

A simple, portable capillary refill time (CRT) simulator is not commercially available. This device would be useful in mass-casualty simulations with multiple volunteers or mannequins depicting a variety of clinical findings and CRTs. The objective of this study was to develop and evaluate a prototype CRT simulator in a disaster simulation context.

A CRT prototype simulator was developed by embedding a pressure-sensitive piezo crystal, and a single red light-emitting diode (LED) light was embedded, within a flesh-toned resin. The LED light was programmed to turn white proportionate to the pressure applied, and gradually to return to red on release. The time to color return was adjustable with an external dial. The prototype was tested for feasibility among two cohorts: emergency medicine physicians in a tabletop exercise and second year medical students within an actual disaster triage drill. The realism of the simulator was compared to video-based CRT, and participants used a Visual Analog Scale (VAS) ranging from “completely artificial” to “as if on a real patient.” The VAS evaluated both the visual realism and the functional (eg, tactile) realism. Accuracy of CRT was evaluated only by the physician cohort. Data were analyzed using parametric and non-parametric statistics, and mean Cohen’s Kappas were used to describe inter-rater reliability.

The CRT simulator was generally well received by the participants. The simulator was perceived to have slightly higher functional realism (P=.06, P=.01) but lower visual realism (P=.002, P=.11) than the video-based CRT. Emergency medicine physicians had higher accuracy on portrayed CRT on the simulator than the videos (92.6% versus 71.1%; P<.001). Inter-rater reliability was higher for the simulator (0.78 versus 0.27; P<.001).

A simple, LED-based CRT simulator was well received in both settings. Prior to widespread use for disaster triage training, validation on participants’ ability to accurately triage disaster victims using CRT simulators and video-based CRT simulations should be performed.

ChangTP, SantillanesG, Claudius I, PhamPK, KovedJ, CheyneJ, Gausche-HillM, KajiAH, SrinivasanS, DonofrioJJ, BirC. Use of a Novel, Portable, LED-Based Capillary Refill Time Simulator within a Disaster Triage Context. Prehosp Disaster Med. 2017;32(4):451–456.

In early 2015, a patient from a cluster of cases of Ebola Virus Disease (EVD) in Monrovia, Liberia traveled to a rural village in Margibi County, potentially exposing numerous persons. The patient died in the village and post-mortem testing confirmed Ebola Virus infection.

The Margibi County Health Team (CHT; Kakata, Margibi, Liberia) needed to prevent further transmission of EVD within and outside of the affected villages, and they needed to better understand the factors that support or impede compliance with measures to stop the spread of EVD.

In February-March 2015, the Margibi CHT instituted a 21-day quarantine and active monitoring for two villages where the patient had contact with numerous residents, and a 21-day active monitoring for five other villages where the patient had possible contact with an unknown number of persons. One contact developed EVD and quarantine was extended an additional 12 days in one village. In April 2015, the Margibi CHT conducted a household-based EVD knowledge, attitudes, and practices (KAP) survey of the seven villages. From April 24-29, 2015, interview teams approached every household in the seven villages and collected information on demographics, knowledge of EVD, attitudes about quarantine to prevent the spread of EVD, and their quarantine experiences and practices. Descriptive statistics were calculated.

One hundred fifteen interviews were conducted, representing the majority of the households in the seven villages. Most (99%) correctly identified touching an infected person’s body fluids and contact with the body of someone who has died from EVD as transmission routes. However, interviewees sometimes incorrectly identified mosquito bites (58%) and airborne spread (32%) as routes of EVD transmission, and 72% incorrectly identified the longest EVD incubation period as ≤seven days. Eight of 16 households in the two quarantined villages (50%) reported times when there was not enough water or food during quarantine. Nine of 16 (56%) reported that a household member had illnesses or injuries during quarantine; of these, all (100%) obtained care from a clinic, hospital, or Ebola treatment unit (ETU).

Residents’ knowledge of EVD transmission routes and incubation period were suboptimal. Public health authorities should consider assessing residents’ understanding of Ebola transmission routes and effectively educate them to ensure correct understanding. Quarantined residents should be provided with sufficient food, water, and access to medical care.

WilkenJA, PordellP, GoodeB, JartehR, MillerZ, SaygarBGSr., MaximoreL, BorborWM, CarmueM, WalkerGW, YeiahA. Knowledge, Attitudes, and Practices among Members of Households Actively Monitored or Quarantined to Prevent Transmission of Ebola Virus Disease — Margibi County, Liberia: February-March 2015. Prehosp Disaster Med. 2017;32(6):673–678.

Select units in the military have improved combat medic training by integrating their functions into routine clinical care activities with measurable improvements in battlefield care. This level of integration is currently limited to special operations units. It is unknown if regular Army units and combat medics can emulate these successes. The goal of this project was to determine whether US Army combat medics can be integrated into routine emergency department (ED) clinical care, specifically medication administration.

This was a quality assurance project that monitored training of combat medics to administer parenteral medications and to ensure patient safety. Combat medics were provided training that included direct supervision during medication administration. Once proficiency was demonstrated, combat medics would prepare the medications under direct supervision, followed by indirect supervision during administration. As part of the quality assurance and safety processes, combat medics were required to document all medication administrations, supervising provider, and unexpected adverse events. Additional quality assurance follow-up occurred via complete chart review by the project lead.

During the project period, the combat medics administered the following medications: ketamine (n=13), morphine (n=8), ketorolac (n=7), fentanyl (n=5), ondansetron (n=4), and other (n=6). No adverse events or patient safety events were reported by the combat medics or discovered during the quality assurance process.

In this limited case series, combat medics safely administered parenteral medications under indirect provider supervision. Future research is needed to further develop this training model for both the military and civilian setting.

SchauerSG, CunninghamCW, FisherAD, DeLorenzoRA. A Pilot Project Demonstrating that Combat Medics Can Safely Administer Parenteral Medications in the Emergency Department. Prehosp Disaster Med. 2017;32(6):679–681.

Health care providers are on the forefront of delivering care and allocating resources during a disaster; however, very few are adequately trained to respond in these situations. Furthermore, there is a void in the literature regarding the specific care needs of patients with ventricular assist devices (VADs) in a disaster setting. This project aimed to develop an evidenced-based protocol to aid health care providers during the evacuation of patients with VADs during a disaster.

This is a qualitative study that used expert review, tabletop discussion, and a survey of health care professionals to develop and evaluate an evacuation protocol. The protocol was revised after each stage of review in order to reach a consensus document.

The project concluded with the finalization of a protocol which addresses evacuation and patient triage, and also includes an algorithm to determine which staff members should be evacuated with patients, transportation resources, evacuation documentation, and items patients need during evacuation. The protocol also addressed steps to be taken in the event that evacuation efforts fail and how to manage outpatient VAD patients seeking assistance.

This protocol provides guidance for the care of VAD patients in the event of a disaster and evacuation. Protocols such as this address difficult scenarios and should be created prior to a disaster to assist staff in making difficult decisions. These documents should be created using multi-disciplinary feedback via the consensus model as well as the Institute of Medicine (IOM; National Academy of Medicine; Washington, DC USA) “Crisis Standards of Care.”

DavisKJ, SuyamaJ, LinglerJ, BeachM. The Development of an Evacuation Protocol for Patients with Ventricular Assist Devices During a Disaster. Prehosp Disaster Med. 2017;32(3):333–338.