BackgroundDamage control resuscitation describes an approach to the early care of very seriously injured patients. The aim is to keep the patient alive whilst avoiding interventions and situations that risk worsening their situation by driving the lethal triad of hypothermia, coagulopathy and acidosis or excessively stimulating the immune-inflammatory system. It is critical that the concepts and practicalities of this approach are understood by all those involved in the early management of trauma patients. This review aims to summarise this and discusses current knowledge on the subject.InterventionsDamage control resuscitation forms part of an overall approach to patient care rather than a specific intervention and has evolved from damage control surgery. It is characterised by early blood product administration, haemorrhage arrest and restoration of blood volume aiming to rapidly restore physiologic stability. The infusion of large volumes of crystalloid is no longer appropriate, instead the aim is to replace lost blood and avoid dilution and coagulopathy. In specific situations, permissive hypotension may also be of benefit, particularly in patients with severe haemorrhage from an arterial source. As rapid arrest of haemorrhage is so important, team-based protocols that deliver patients rapidly but safely, via CT scan where appropriate, to operating theatres or interventional radiology suites form a critical part of this process.ConclusionsGiven that interventions are so time dependent in the severely injured, it is likely that by further improving trauma systems and protocols, improvements in outcome can still be made. Further research work in this area will allow us to target these approaches more accurately to those patients who can benefit most.

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Background— There are limited data on outcomes of patients with previous coronary artery bypass grafting (CABG) presenting with ST-segment–elevation myocardial infarction (STEMI) and undergoing primary percutaneous coronary intervention (PPCI). We report outcomes in patients with STEMI undergoing PPCI with or without previous CABG surgery in a large real-world, all-comer population. Methods and Results— Clinical, demographic, procedural, and outcomes data were collected for all patients undergoing PPCI in England and Wales from January 2007 to December 2012. All-cause mortality at 30 days and 1 year were evaluated in the whole and a propensity-matched cohort. Of 79 295 patients with STEMI studied, 2658 (3.4%) patients had prior CABG, of whom 44% (n=1168) underwent PPCI to native vessels and 56% (n=1490) to bypass grafts. There were significant differences in the demographic, clinical, and procedural characteristics of these groups. Patients with prior CABG (with primary PCI to native artery or graft) had higher mortality at 30 days (6.2% with PPCI to native artery, 6.1% with PPCI to bypass graft) than patients with no prior CABG (4.5%; P <0.001). However, after risk factor adjustments, there was no significant difference in outcomes. There were also no significant differences in 30-day mortality, in-hospital major adverse cardiovascular events, in-hospital stroke, and in-hospital bleeding in the propensity-matched population. Conclusions— A prior history of CABG in patients presenting with STEMI and undergoing PPCI does not independently confer additional risk of mortality, although it is a marker of other high-risk features.

Objectives Frailty is common amongst patients undergoing transcatheter aortic valve implantation (TAVI). The aim of this study was to determine the prognostic relevance of newer objective and traditional measures of frailty after TAVI. Methods Consecutive patients were identified from the Leeds Teaching Hospitals Trust TAVI database. Frailty was quantified objectively by measuring the total psoas muscle area (TPMA) on routine computer tomography scans and compared against Canadian Study of Health and Aging Clinical Frailty Score, Katz Index of independence in activities of daily living and Clinician Estimated Poor Mobility. Postintervention morbidity and mortality were examined between these scoring systems. Results The current study included 420 patients who had undergone TAVI between January 2013 and December 2015. Median clinical follow-up was 4.0 years (interquartile range 2.9–5.0). Standardized measurements of the TPMA were not associated with either postintervention morbidity or mortality. Only the Canadian Study of Health and Aging Clinical Frailty Score was associated with hospital stay (adjusted regression coefficient 0.70, 95% confidence interval 0.04–1.36, P = 0.038) and overall all-cause mortality (adjusted regression coefficient 1.26, 95% confidence interval 1.05–1.50, P = 0.013). There were no significant correlations between TPMA and any of the traditional frailty tools. Conclusion We demonstrate TPMA to be a poor measure of patient frailty when compared with traditional methods of assessment which failed to predict postintervention outcomes. Furthermore, morphometric sarcopaenia correlated poorly with established measures of frailty.

With an ever-ageing population, the incidence of hip fractures is increasing worldwide. Increasing age is not just associated with increasing fractures but also increasing comorbidities and polypharmacy. Consequently, a large proportion of patients requiring hip fracture surgery (HFS) are also prescribed antiplatelet and anti-coagulant medication. There remains a clinical conundrum with regards to how such medications should affect surgery, namely with regards to anaesthetic options, timing of surgery, stopping and starting the medication as well as the need for reversal agents. Herein, we present the up-to-date evidence on HFS management in patients taking blood-thinning agents and provide a summary of recommendations based on the existing literature.

OBJECTIVE Obesity and diabetes frequently coexist, yet their individual contributions to cardiovascular risk remain debated. We explored cardiovascular disease biomarkers, events, and mortality in the UK Biobank stratified by BMI and diabetes. RESEARCH DESIGN AND METHODS A total of 451,355 participants were stratified by ethnicity-specific BMI categories (normal, overweight, obese) and diabetes status. We examined cardiovascular biomarkers including carotid intima-media thickness (CIMT), arterial stiffness, left ventricular ejection fraction (LVEF), and cardiac contractility index (CCI). Poisson regression models estimated adjusted incidence rate ratios (IRRs) for myocardial infarction, ischemic stroke, and cardiovascular death, with normal weight nondiabetes as comparator. RESULTS Five percent of participants had diabetes (10% normal weight, 34% overweight, and 55% obese vs. 34%, 43%, and 23%, respectively, without diabetes). In the nondiabetes group, overweight/obesity was associated with higher CIMT, arterial stiffness, and CCI and lower LVEF (P &lt; 0.005); these relationships were diminished in the diabetes group. Within BMI classes, diabetes was associated with adverse cardiovascular biomarker phenotype (P &lt; 0.005), particularly in the normal weight group. After 5,323,190 person-years follow-up, incident myocardial infarction, ischemic stroke, and cardiovascular mortality rose across increasing BMI categories without diabetes (P &lt; 0.005); this was comparable in the diabetes groups (P-interaction &gt; 0.05). Normal weight diabetes had comparable adjusted cardiovascular mortality to obese nondiabetes (IRR 1.22 [95% CI 0.96–1.56]; P = 0.1). CONCLUSIONS Obesity and diabetes are additively associated with adverse cardiovascular biomarkers and mortality risk. While adiposity metrics are more strongly correlated with cardiovascular biomarkers than diabetes-oriented metrics, both correlate weakly, suggesting that other factors underpin the high cardiovascular risk of normal weight diabetes.