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Apr 20, 2023 16 tweets 13 min read Read on X
➡️ Throughout history, the most mystical substance of all has been blood
➡️ It has been coveted and desired
➡️ Fought for and defended
➡️ Stolen, yet freely given

A 🧵

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➡️ Blood has always been a symbol of power
➡️ In Greek mythology, ichor, the blood of the Gods, was a golden fluid
➡️ It was immortal, pure, & untainted by human weaknesses
➡️ The Gods derived their divine powers & longevity from it

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➡️ Blood has been revered for its restorative properties
➡️ Elizabeth Báthory, a 16th-century Hungarian noblewoman, allegedly killed hundreds of young girls & women
➡️ She bathed in their blood to maintain her youth & beauty

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➡️ Blood was highly valued
➡️ In 1487, the Aztec ruler Ahuitzotl ordered a blood sacrifice to honor the gods Huitzilopochtli & Tlaloc
➡️ Over 4 days, up to 80,000 captured warriors had their still-beating hearts cut out on the Great Temple's sacrificial altar

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➡️ Their bodies were tossed down the temple side and dismembered below
➡️ The skulls were added to the tzompantli, or skull rack
➡️ The Aztecs believed that Huitzilopochtli, the Sun God, required nourishment from human blood to continue his daily journey across the sky

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➡️ Blood is also deeply personal, a reflection of one's uniqueness & being
➡️ Tales of its theft are psychologically traumatic
➡️ One of the best known stories capturing this fear is Bram Stoker's Dracula
➡️ Written in 1897, it remains hugely popular & terrifying

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➡️ Vital for life, blood is also precious
➡️ Early attempts to halt bleeding involved many different substances from the natural world
➡️ Spiderwebs have been used in many civilisations over time
➡️ In addition to their strong laced structure, they also contain vitamin K

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➡️ In WW1 soldiers from both sides used Sphagnum (bog) moss
➡️ With absorbent & antiseptic properties, it promoted clotting & prevent infection
➡️ The moss could hold 22 times its volume in blood
➡️ It also reduced wound pH, preventing microbial growth

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➡️ Not all efforts were successful.....
➡️ In ancient Rome, the physician Galen documented the use of horse dung for bleeding
➡️ It was applied directly to the wound
➡️ The warmth and pressure from the dung were believed to promote clotting & prevent infection

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➡️ Today, haemostatic measures are slightly more scientific

➡️ Tranexamic acid has been tested and is currently recommended for major traumatic haemorrhage
➡️ The upcoming @PATCHTrial results will confirm or refute the findings of previous studies like CRASH-2

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@PATCHTrial ➡️ Plasma fibrinogen levels drop in traumatic haemorrhage
➡️ Fresh frozen plasma contains ~ 70% of the clotting factors of fresh blood
➡️ FFP alone is unable to increase plasma fibrinogen to > 2g/L, similar to normal plasma

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@PATCHTrial ➡️ Cryoprecipitate, rich in fibrinogen, can increase the levels of this haemostatic factor
➡️ Whether this is beneficial in traumatic haemorrhage is unknown
➡️ The upcoming @CRYOSTAT_2 results presentation at #CCR23 will provide an answer

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@PATCHTrial @CRYOSTAT_2 ➡️ 4-factor prothrombin complex concentrate contains coagulation factors II, VII, IX, & X plus proteins S and C
➡️ It was hoped it would decrease blood product use in trauma resuscitation & improve outcomes
➡️ Sadly, it didn't, but did cause more thrombotic events

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@PATCHTrial @CRYOSTAT_2 ➡️ Published in @JAMA_current current last month, the PROCOAG trial adds to the evidence base for haemostatic resuscitation in trauma
➡️ Along with @CRYOSTAT_2, @PATCHTrial & @UKREBOATrial, the best recent trauma trials will be presented together at #CCR23

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@PATCHTrial @CRYOSTAT_2 @JAMA_current @UKREBOATrial ➡️ Join us in @TitanicBelfast to hear the discussions at #CCR23
➡️ The chief investigators for all 4 trials will be present
➡️ Pierre Bouzat will present the PROCOAG trial
➡️ How will we haemostatically resuscitate patients post #CCR23?
criticalcarereviews.com/meetings/ccr23

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@PATCHTrial @CRYOSTAT_2 @JAMA_current @UKREBOATrial @TitanicBelfast ➡️ #CCR23 is supported by
🔴 @VisitBelfast
🔴 @belfastcc
🔴 @NITouristBoard
🔴 @BelfastTrust

See you in Belfast in June

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More from @CritCareReviews

May 4, 2023
➡️ Antimicrobial therapy has been used for millennia
➡️ Treating severe infections can be lifesaving
➡️ However, the widespread use of antimicrobials also has downsides

A 🧵

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➡️ Throughout history, honey, herbs & metals were often used
➡️ One of the earliest known antimicrobial therapies was the topical use of mouldy bread
➡️ This intervention has been recorded in many ancient civilisations, including Egypt, China, Serbia, Greece & Rome

2/16 Image
➡️ Mercury was used for epidemic diseases since the 1300s & especially syphilis
➡️ However, the treatment could be worse than the disease, with mercury poisoning possible
➡️ Treatment could last years, leading to the saying “A night with Venus, a lifetime with mercury”"

3/16 Image
Read 16 tweets
Apr 6, 2023
➡️ There are ~ 5.8 million trauma deaths per year globally
➡️ Trauma is the largest cause of death below the age of 50
➡️ One-third of severely injured trauma patients are coagulopathic at hospital arrival
➡️ Fibrinogen is often used, but is it effective?

a short 🧵

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➡️ Trauma-induced coagulopathy is due to inflammation & shock
➡️ It is worsened by hypothermia, acidosis, and hemodilution
➡️ Coagulopathy due to hemorrhage is strongly associated with mortality
➡️ 1/3 of early trauma deaths are due to uncontrolled haemorrhage

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➡️ Fibrinogen is depleted early during major bleeding
➡️ It can be replaced with fresh frozen plasma, cryoprecipitate or fibrinogen concentrate
➡️ Cryoprecipitate includes fibrinogen, factor VIII coagulant, von Willebrand factor, fibronectin & factor XIII

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Read 10 tweets
Apr 4, 2023
➡️ Death has always fascinated human civilisations
➡️ Not just the ending of a life, but either preparation for the afterlife or attempts to restore an existing life

A 🧵

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➡️ Ancient Egyptians preserved corpses via mummification for an afterlife
➡️ They removed internal organs, used embalming fluids, linen bandages, & intricate coffins
➡️ The wealthy had pyramids
➡️ Relatives, staff & pets were buried alive for the journey to the afterlife

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➡️ In Greek Mythology, the River Styx separated the worlds of the living & dead
➡️ Charon, the Ferryman, required payment from the deceased for passage
➡️ The dead were buried with a coin
➡️ Those unable to pay were left to wander the river bank for 100 years

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Read 28 tweets
Mar 23, 2023
🚩 Tranexamic Acid - it's complicated....

➡️It's widely used for treatment & prevention of haemorrhage
➡️It's in the WHO's List of Essential Medicines & recommended in the European Traumatic Haemorrhage guideline (2023)
➡️But is it as efficacious as we think?

🧵 1/17
🚩 History

➡️Drs. Utako & Shosuke Okamoto invented TXA in 1962
➡️They identified that the amino acid lysine inhibited the degradation of plasmin, a profibrinolytic enzyme
➡️Lysine was modified to first produce Epsilon- Amino-Caproic Acid and later TXA, x 27 more potent

2/17
🚩 Pharmacology

➡️TXA is a molecular analog of lysine
➡️It inhibits fibrinolysis by preventing the binding of plasminogen to fibrin
➡️This inhibits plasmin formation & displaces plasminogen from the fibrin surface
➡️It also has effects on the immune system & inflammation

3/17
Read 18 tweets
Mar 21, 2023
The Annual Update in Intensive Care and Emergency Medicine 2023 articles have been released to coincide with the Brussels Meeting @ISICEM

10 great papers to enjoy

A thread.....

CCR Journal Watch
criticalcarereviews.com/latest-evidenc…
@ISICEM 1/10

Pelaia. The Role of Transcriptomics in Redefining Critical Illness. Crit Care 2023;27:89

CCR Journal Watch
criticalcarereviews.com/latest-evidenc…
@ISICEM 2/10

Neyton. Metagenomic Sequencing in the ICU for Precision Diagnosis of Critical Infectious Illnesses. Crit Care 2023;27:90

CCR Journal Watch
criticalcarereviews.com/latest-evidenc…
Read 11 tweets
Mar 20, 2023
1/13

➡️ REBOA is an exciting "new" therapy for non-compressible torso haemorrhage
➡️ It's used across the world, but without robust evidence
➡️ Does it work? Is it beneficial?
➡️ A thread...
2/13

🚩 Uncontrollable haemorrhage accounts for
 ➡️ > 80% of combat deaths
  ➡️ ~ 40% of civilian trauma-related deaths
🚩 Many have been determined to be preventable deaths
🚩 ~ 67% of fatal bleeding occurs in the torso region
3/13

Emergency thoracotomy (ET) has a long history in resuscitation

🚩 1880 - Paul Niehans first documented ET in human cardiac arrest
🚩 1901 - Kristian Ingelsrud performed the first successful resuscitation
🚩 1953 - Stephenson had 28% survival in 1200 cardiac arrests
Read 13 tweets

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