DIY to Stop the Blood

This thing comes from Dr Andrew Weatherall, paediatric anaesthetist and prehospital doc. He also blogs over at


I don’t do DIY. This is partly because in the same way I wouldn’t expect a carpenter to have a crack at fixing their kids’ bones in preference to seeing an orthopod, I think it makes sense to use professionals.

It’s also because I’m just not that great at it. Anything I did make would end up looking like something trying to squeeze itself into the shape of the thing it is sort of supposed to be. And I’m fond enough of my family to want to protect them from the risks of my own handiwork.

Here's one I prepared earlier (via CC and flickr user mhlradio)
Here’s one I prepared earlier (via CC and flickr user mhlradio)

Anyway, I do paediatric anaesthesia. I get to spend more than enough time trying to make things that aren’t quite right for the situation fit in with what I need. Why DIY at home when you have to DIY at work?


Making Things Fit

The problem with paeds practice is that kids are sometimes kids and sometimes little adults and often forgotten in research. Or if not forgotten put in the category of “the ethics and logistics of that will be so painful I’d rather remove my spleen via my auditory canal”. And in trauma care we’re also dealing with total numbers that are lower than is the case for adults.

So what we end up with is lots of extrapolation from adult data and lots of retrospective studies sprinkled with the occasional fairy dust of a small case series. Then we have to try and mash those leftovers together to come up with a plan for a very specific situation.

An example: how about tranexamic acid in trauma?


Making It Up

Following on from CRASH-2 and MATTERs, what to do in the younger generation is an obvious question. A big prospective study in kids after trauma would be perfect. And a pipe dream.

So if you turn to the literature what you see is a large number of people trying out archery on summer camp and hitting many, many different targets while all shooting vaguely in the same area.

To corral some of them in one spot, take the review by Faraoni and Goobie looking at antifibrinolytics in non-cardiac surgery in kids. All of the following values are listed as loading doses in the scoliosis and craniofacial groups: 10, 15, 20, 50, 100 and 1000 mg/kg with infusions anywhere from 1 mg/kg/hr up to 100 mg/kg/hr. In the scoliosis patients there are total numbers of up to 80 patients and slightly baffling figures suggesting total blood loss is decreased but transfusion requirement pretty much the same. Or that in the craniofacial surgery group it seems like probably there might be slightly less blood loss and transfusion needs.

But in paediatric cardiac surgery there might be more seizures too, even though the overall safety profile looked pretty good. Nothing definitive though. Such clarity.

So now the job is to consider how to take this magnificently imperfect evidence and apply it to a specific and different clinical scenario, trauma.



The Pragmatist

The Royal College of Paeditrics and Child Health and the National Paediatric Pharmacists Group Joint Committee had exactly this challenge back in 2012. It’s the intellectual equivalent of trying to catch pancake batter. Messy.

Ultimately they chose what they termed the pragmatist’s option – 15 mg/kg loading (up to 1 g) over 10 minutes then an infusion of 2 mg/kg/hr. Maybe enough to do something, but with a homeopathic infusion so you were unlikely to get complications. Entirely rational in the absence of evidence too.

But what if there was another approach?


Another Way

What they didn’t have access to was some recent data out of the UK military Afghanistan experience in Camp Bastion. TXA had become standard for adult trauma patients under certain conditions after the release of CRASH-2 and both editions of MATTERs. These sort of treatment centres don’t just receive adults though and they must have been wrestling with what to do in smaller patients.

What they describe is another type of pragmatic approach. Rather than any adjustment they just did what they were already doing. Tranexamic acid in a 1 g dose for all comers and more on the basis of medical assessment (though it looks like no one got another dose).

This gets past lots of problems, particularly with getting accurate weights or ages and the need to learn different treatment regimes. It also comes with a certain amount of glee, not because you’re sort of saying “kids are just little adults” and you know that would break plenty of people. You’re actually saying “kids are adults”. If you say that 3 times while drawing a pentagram in a circle of candles, somewhere a paediatrician will be woken with a pain between their shoulder blades.

They describe a breakdown of 66 patients under 18 getting TXA and 700 without TXA. Having severe abdominal or extremity injuries and showing evidence of severe metabolic acidosis were significant predictors that TXA would be used. TXA use was independently associated with reduced mortality but no great difference in packed red blood cell/fresh frozen plasma transfusion ratios. Intriguingly in those getting a large volume transfusion, receiving TXA was associated with greatly improved neurologic status at the time of discharge (now that opens up a need for more work). They didn’t note an increased risk of thromboembolic complications (but they probably don’t have the numbers to be sure about that).

Overall, we’re talking about kids with an average age of 11 so using the equation of (3 x age) + 7, the weight might be about 40 kg (though I’m not certain if the weights might be a bit less than algorithms from developed countries). That would mean a starting dose averaging round 25 mg/kg.


The Other Extra Bit

That 2014 review also mentions an additional titbit that’s a little useful. Some pharmacokinetic work has been done in patients with craniofacial surgery patients and it appears that an upfront dose of 10 mg/kg then an infusion of 5 mg/kg/hr is optimal for establishing appropriate drug levels. This is far more useful information than cardiac surgery pharmacokinetics where additional considerations of dilution by bypass circuits, potential for pre-existing cyanosis and a variety of other factoids make it hard to draw comparisons. So 10 mg/kg might be enough initially but the subsequent infusion should probably be more than a scattering of holy water (as in more than 2 mg/kg).


The Bottom Line

We’re still stuck with not enough information about paediatric patients. Will there be a bigger study in paeds trauma soon? Probably not. But we can say with more confidence than before that doses that are pretty big seem to be OK.

So what would I do now? I’d modify the pragmatic plan and go with a 20 mg/kg loading dose (or 0.2 mL/kg of our current stock) and once in hospital I’d go with an infusion of 5-10 mg/kg/hr.

And I’d still hope someone is going to try to build a better shack.



Are you after that review? It’s Faraoni D and Goobie SM. The Efficacy of Antifibrinolytic Drugs in Children Undergoing Noncardiac Surgery: A Systematic Review of the Literature. Anesth Analg 2014;118:628-36.  

Or maybe the RCPCH statement on using TXA in trauma – try here.

And here’s the Pubmed listing for the newer trauma study – Eckert MJ, Wertin TM, Tyner SD et al. Tranexamic acid administration to pediatric trauma patients in a combat setting: The pediatric trauma and tranexamic acid study (PED-TRAX). J Trauma Acute Care Surg. 2014;77:852-8. 

And in case you didn’t have it already, here’s the spot for the [(3 x age) + 7] calculation. Luscombe MD, Owens BD, Burke D. Weight estimation in paediatrics: a comparison of the APLS formula and the formula ‘Weight = 3(age)+7’ Emerg Med J 2011;28:590-3. 

Thoughts from the Control Tower

This is the first of what we hope will be a series of posts from Dr Paul Bailey who works as a Medical Director for CareFlight International Air Ambulance. Paul will try to provide insights into the challenges of managing retrievals across oceans. Here’s the starter. 

In his real life, Paul Bailey is an Emergency Physician based in Perth, Western Australia who dabbles in the Greyhound racing industry (having owned 10 dogs and never been to the track).  He can often be found in the outer at an Aussie Rules football oval, most commonly critiquing the performance of the umpires in an entirely constructive manner.  Past lives include a molecular biology PhD – in Jellyfish venom – don’t ask – and being a glassy in various drinking establishments in Western Australia. 

 Paul has previously undertaken international retrievals, helicopter work supporting Australian Army exercises and time with Queensland Rescue at Cairns. He now makes cameo appearances on the International Medical Director roster, as a medical director for retrievals in the NT and the Inpex oil and gas business.


If you’ve decided to be involved in retrieval, why think local when you can think global? After many years of toiling through school, then medical school, and then advanced training in the acute care specialty of your choice, you’re now in the hot seat ready to go.

Living the Dream

You’ve always fancied yourself as an airborne medico ever since you sat on your Dad’s knee watching “The Flying Doctors” in the late ‘80s and thinking how cool that would be. Truth be told, you also liked Top Gun and from time to time have drawn a laugh with the immortal line: “Negative Ghostrider, the pattern is full.” But you still buzzed the control tower anyway.

Fly Past copy

Or perhaps more likely you rode that little bit too close to your Mum on your BMX. You’ve also heard, along the way that everyone in retrieval gets a nickname and you’re tossing up between Maverick and Goose.

Top Gun copy

And it’s safe to say you have bought the Ray Ban Aviators already.


Living the Reality

So what’s it really like? Different to that, not surprisingly.

CareFlight International Air Ambulance (CFIAA) is an ever changing beast, with our clinical teams and aircraft based in Darwin and Sydney. Over the journey we have also had aircraft in Perth and Cairns. Depending on where the team is on duty, they are most likely to be flying between Indonesia, East Timor, Papua New Guinea, Darwin and Adelaide (for Darwin crews) and Fiji, Noumea, Norfolk Island, Sydney and Brisbane if you are based in Sydney. Of course, it’s international so there actually isn’t a spot on the globe that shouldn’t be thought of as up for grabs.

Co-ordinators and Medical Directors sit behind the team at all times and, due to the miracle of mobile phones and the internet can be almost anywhere. Many of these folk never meet in person but are always looking over everybody’s shoulder.

More of that later, in this awe inspiring opening to the series I though I’d start with how it all gets going – who pays for it all?


The People with the Deep Pockets – Travel Insurers and Governments

When your average citizen takes out travel insurance, it is most likely to protect against such tragedies as losing an iPhone overseas, dropping a wallet in the ocean or perhaps finding himself in Vietnam and his luggage in downtown Boston. Having been in this game a while now, it is my opinion that if losing your iPhone is the worst thing that happens on your holiday you’ve had a pretty good time.

Recliners copy

It may surprise you to know that a travel insurance policy is, by and large, a health insurance policy. Greater than 95% of the spend of travel insurance companies relates directly to health costs.

Each travel insurer has a series of service providers sitting behind them, one of which is an assistance company. There are a relatively small number of assistance companies that engage in this type of work. They have 24h call centres with co-ordinators, nurses and doctors (much like us).

In the event that John Q Citizen becomes unwell or is injured whilst they are away – by getting gored by a bull in Pamplona for instance – they or their relatives call the assistance company and a whole train of events unfolds, which might include directing patients towards local health care facilities to help with their medical problems.

The assistance company will maintain contact with the now patient and their family, and depending on how things in the event that the medical issue is of a serious nature, things tend to pan out in one of two ways that relate to the quality of health care available locally and the underlying urgency of the patient’s medical condition.

Let’s focus on the sicker end of the spectrum because clearly many issues are of a minor nature and never come anywhere near us.

If “definitive care” is available locally AND the quality of local medical care is high AND treatment of the matter is urgent assistance companies will usually head down the route of electing to keep the patient where they are for treatment in the theory that that is both (a) best for the patient and (b) cheaper than an international medical retrieval.

If “definitive care” is NOT available locally OR the quality of local medical care is questionable it is then the key decisions become urgency and mode of transport.  There are, again, an array of transport options available but seeing as we are in the Air Ambulance business, again we might focus on that.


Send in the Big Bird

The assistance company, having decided that medical evacuation is required and that this is most appropriately by air ambulance asks its panel of Air Ambulance providers for a quote. At this stage, the available information usually consists of the patient location and their ultimate destination. No clinical information is available.

Our co-ordinator submits a quote, and due to the price of aviation fuel the retrieval company with the aircraft that has to do the least amount of flying to get the job done is usually cheapest. Paperwork is exchanged and the job confirmed.

Clinical information is then available and at this stage the CFIAA Medical Director is brought into the discussion – to liaise with treating clinicians at the hospital of origin as well as the destination unit. How many times is it quick and easy to have a chat with someone you’ve never met in the hospital? Well, it is fair to say that these conversations can be difficult – finding the right person in an overseas hospital at a sometimes odd times of day and surmounting the language barrier is not straightforward.

We are often going to locations where the quality of the medical and nursing staff are excellent but the broad array of diagnostic equipment that many of us consider routine are just not available. Similarly there are many locations where the patient will have a problem that is unable to be treated effectively with the resources available locally. It’s part of the game, and in many ways it’s why we are needed in the first place. A lot of the legwork for the coordinator is about trying to construct a story that is useful for the retrieval team and help plan for every contingency.

So, that’s a summary of all the things that happen before you get to find out about a case. We haven’t even got to the challenges of the actual patient yet.

I might finish off with a thought for the day:

If you can open your packs blindfolded, upside down and in a thunder storm – and know where everything will be, you have satisfactorily completed orientation.