Research Forum Abstracts
351 Hematologic Findings of Venom-Induced
Consumption Coagulopathy following Korean
Viper (Gloydius Species) Bite
Yoon JC, Kim SE, Ock S, Jo S, Jeong TO, Lee JB, Jin YH/Chonbuk National University
Hosptial, Jeonju-si, Korea, Republic of
Study Objectives: Recent studies have demonstrated that coagulopathy following
snake envenomation is a venom-induced consumption coagulopathy (VICC), in which
venom activates coagulation factors at specific points rather than an entire pathway.
The objectives of this study were to determine what factors are consumed when severe
coagulopathy after Korean viper (Gloydius species) bite develops and what factors
should be used to monitor the venom activity.
Methods: We retrospectively investigated the medical records of 244 patients
who were admitted to our emergency department (ED) from 2011 to 2016 due to
snake envenomation. There were 25 patients (10.2%) of severe coagulopathy
defined as international normalized ratio (INR) > 3.0 with or without
unmeasurable activated partial thromboplastin time (aPTT) and/or
hypofibrinogenemia (< 100 mg/dl). Coagulation factor levels were checked at
onset of severe coagulopathy. The onset time, treatment, and recovery time of
severe coagulopathy were noted.
Results: Most cases of severe coagulopathy (23/25, 88.0%) developed lately
(> 12 hours after the bite). All patients (20/20) showed hypofibrinogenemia.
Decreased levels of factors II, V, and VIII were observed in 2 (10.5%), 10
(52.6%), and 3 (15.8%) patients, respectively, of the total 19 patients. Among
these, 2 patients showed severe coagulation factor deficiency (< 30%) rather than
fibrinogen in factor V. Fibrin(ogen) degradation product (FDP) and d-dimer levels
were increased in all patients who were tested. Only 2 patients (of 19) showed a
mildly decreased anti-thrombin III level. Increase of fibrinogen levels was
paralleled by decrease of FDP levels as treatment with antivenin and fibrinogen-
rich product were started.
Conclusions: This study showed isolated hypofibrinogenemia and
hyperfibrin(ogen)olysis are major hematologic findings of VICC following Korean
viper bite. We suggest that the FDP level reflect the effect of venom and should be
monitored during treatment for severe coagulopathy.
352 A Comparison of Flow Rates and
Hematologic Safety Between Intraosseous
Blood Transfusion Strategies in a Swine
(Sus scrofa) Model of Hemorrhagic Shock:
A Pilot Study
Krepela A, Auten J, Mclean J, Fortner G, Murnan S, Kemp J, Roszko P, Fishback J,
Combat Trauma Research Group/Naval Medical Center Portsmouth, Norfolk, VA
Study Objectives: Intraosseous (IO) access is used by military first responders
administering fluids, blood, and medications during remote damage controlled
resuscitation (rDCR). In cases where access is difficult, IO lines provide a non-
collapsible method that serves as a bridge to therapy while preparations are made
for central venous access. Increasing degrees of transfusion pressure are required to
overcome the difference between bone and systemic circulation and improve flow
rates. Current military IO transfusion strategies include gravity, pressure bags,
rapid transfusion devices, and manual push-pull through a three way stopcock. The
clinical effects of different pressurized IO transfusion strategies in skeletally
mature adults are not fully understood. The goal of this pilot was to compare four
different IO blood transfusion strategies utilized with varying degrees of
transfusion pressure in a porcine model with bone density similar to an adult
military servicemember.
Methods: Subjects (n¼9) were placed under general anesthesia and vascular
access was achieved. Through a controlled hemorrhage model, 20-25% of the
subjects estimated blood volume was removed using the flow of gravity. The IO
device was placed in the proximal humerus and 10-15% of the subject’s blood
was infused autologously via one of the four methods assigned at random.
Subjects were monitored 1 hour post infusion, blood was analyzed for lactate,
thromboelastogram (TEG) and arterial blood gas values. Surviving animals
were euthanized while under general anesthesia and samples collected. Two
Volume 70, no. 4s : October 2017
samples from upper and lower left lung were collected to assess for gross
evidence of fat embolism and inflammation. The humerus of the second
animal in each treatment arm was removed and cross sectioned proximal to
transfusion site for histologic evaluation of the effects of transfusion on bony
architecture.
Results: Infusion rates were as follows: gravity 3 and 6 ml/min, Belmont rapid
infuser 31.4 and 31.5 ml/min with an average of 7 overpressure alarms, Single site
gravity 78 ml/min, double site gravity 103 ml/min, push/pull 108 and 110 ml/min.
One animal died 7 minutes into push/pull infusion. The second animal displayed
physiologic evidence of right heart strain; however, recovered after completing infusion.
One animal was lost for analysis secondary to IO malposition through the humerus.
There were no increased rates of inflammation changes in the lungs between arms. No
pulmonary arterial fat embolism were noted. Bony architecture at transfusion site was
unaffected by transfusion strategy.
Conclusions: The optimal IO transfusion strategy for our injured service members
appears to be single site transfusion with a 10-20 ml flush of normal saline followed
immediately by transfusion under 300 mmHg pressure bag in the proximal humerus or
sternum. The push pull and double barrel methods confer a benefit in speed of
transfusion, but should be further studied under the full protocol to determine the
effect increased transfusion pressures have on clinical end points like damage to the
underlying bony matrix, changes in right heart pressures, and increased rates of
hemolysis or pulmonary fat embolism.
EMF
353 Elevation of the Head and Thorax
During Cardiopulmonary
Resuscitation Improves Cerebral
Blood Flow in a Swine Model of
Prolonged Cardiac Arrest
Dodd KW, Moore JC, Segal N, Lick MC, Salverda BJ, Hinke MB, Robinson AE, Debaty G,
Lurie KG/Hennepin County Medical Center, Minneapolis, MN; University of Minnesota,
Minneapolis, MN; Minneapolis Medical Research Foundation, Hennepin County Medical
Center, Minneapolis, MN; University Grenoble Alps/CNRS/CHU de Grenoble Alpes/TIMC-
IMAG UMR 5525, Grenoble, France
Study Objectives: Despite decades of research on cardiopulmonary resuscitation
(CPR), the rate of neurologically intact survival following out-of-hospital cardiac
arrest remains dismal. Blood flow to the brain after 5 minutes of active
compression decompression cardiopulmonary resuscitation (ACD-CPR) with an
impedance threshold device (ITD) in the head-up position (HUP) has been shown
to be higher than supine body position (SUP) in a swine model of cardiac arrest.
Since most CPR efforts last at least 15 minutes, the aim of the study was to
compare cerebral blood flow blood during prolonged HUP and SUP ACD-CPR +
ITD.
Methods: Following anesthetized surgical preparation of female pigs, ventricular
fibrillation (VF) was induced. The animals underwent 8 minutes of untreated VF followed
by 2 minutes of SUP ACD-CPR + ITD with a 30:2 compression:ventilation ratio.
Animals then underwent randomization to treatment with 18 minutes of continuous CPR
in either HUP, in which the head and thorax were elevated at 30 , or SUP with
asynchronous ventilation at 10 breaths per minute and 10 mL/kg. The compression phase
was performed at a rate of 80 per minute with a 50% duty cycle and depth of 22.5% of the
Annals of Emergency Medicine S139