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Hi all, Is it possible for a fatal GSW to the chest to be externally bloodless (as in 100%)? If so, how many times have you seen this in the field? Thank you.

"Hi, I am conducting some research to assess the global potential for a new hand held diagnostic device to accurately measure pupil size and reaction speed. The device has been invented by a Neurologist in the UK and I am working for the National Health Service (Newcastle-upon-Tyne NHS Hospitals Foundation Trust) to bring the device to market...." The rest deleted until Admin can approve. I stopped the survey (the address is part of the delete content) on question two when it demanded information regarding the company that I work for. That appears to make it spam. Also, as the information that you mention regarding pupil data has very limited value prehospital, and per two ER docs I've recently talked to, very little value in any setting with many of it's physiological indications being found to be near useless because their causes are too diverse to be reliably specific, I'm confident that something else is going on here that you're not being completely upfront about. Please send your desired information to webmaster@emtcity.com and the decision can be made as to the best way to get what you want from the City.

Tranexamic acid has been approved for use in the Joint Theater Trauma System Clinical Practice Guidelines, including for prehospital use in patients expected to require massive transfusion. Civilian price is $9/dose, (military price about $1.50/dose) and it is shelf stable at room temperature. CPG is posted on the US Army Institute for Surgical Research website, and is attached here. I believe some civilian prehospital systems will follow suit in the future. 'zilla Excerpt from August 2011 CPG: Joint Theater Trauma System Clinical Practice Guideline Guideline Only/Not a Substitute for Clinical Judgment August 2011 Page 4 of 24 Damage Control Resuscitation At Level IIb/III Treatment Facilities 5. Tranexamic Acid Tranexamic acid (TXA), an anti-fibrinolytic agent, has been used to decrease bleeding and the need for blood transfusions in coronary artery bypass grafting (CABG), orthotopic liver transplantation, hip and knee arthroplasty, and other surgical settings. A recent meta-analysis reported that TXA is effective for preventing blood loss in surgery and reducing transfusion, and was not associated with increased vascular occlusive events. 4 (For additional information concerning TXA, see Appendix D). The early use of TXA (i.e. as soon as possible after injury but ideally not later than 3 hours post injury) should be strongly considered for any patient requiring blood products in the treatment of combat-related hemorrhage and is most strongly advocated in patients judged likely to require massive transfusion (e.g., significant injury and risk factors of massive transfusion). It may be utilized in circumstances when in the judgment of the physician, a casualty has life-threatening hemorrhagic injury and high potential for development of coagulopathy or outright presence of coagulopathy. Use of TXA within 3 hours of injury is associated with the greatest likelihood of clinical benefit. Initial use of TXA after 3 hours post injury may have no benefit and may in fact worsen survival. Therefore it is strongly recommended that TXA not be administered to patients when the time from injury is known to be or suspected to be greater than 3 hours. a. Considerations for Use TXA (intravenous trade name: cyklokapron) is supplied in ampoules of 1000 mg in 10ml water for injection. Infuse 1 gram of tranexamic acid in 100 ml of 0.9% NS over 10 minutes intravenously in a separate IV line from any containing blood and blood products (more rapid injection has been reported to cause hypotension). Hextend® should be avoided as a carrier fluid. Infuse a second 1-gram dose intravenously over 8 hours infused with 0.9% NS carrier. There are presently no data from randomized controlled trials to support administration of further doses to trauma patients. However, if a patient has received the initial dosing of TXA and continues to show signs of ongoing hemorrhage, strong consideration should be given to re-dosing the patient as above. TXA may be administered to patients requiring MT even if they have an associated TBI. Joint Theater Trauma System Clinical Practice Guideline Guideline Only/Not a Substitute for Clinical Judgment August 2011 Page 5 of 24 Damage Control Resuscitation At Level IIb/III Treatment Facilities In patients who continue to have life-threatening hemorrhage despite TXA use and adequate 1:1:1 resuscitation, clinical judgment is warranted as to the use of additional pro-coagulant agents such as rFVIIa. b. Storage Room temperature (15-30° Celsius / 59-86° Fahrenheit). Storage at temperatures great than these may reduce or destroy the efficacy of TXA. 6. Recombinant Factor VIIa (rFVIIa) Recombinant Factor VIIa (rFVIIa) has recently been associated with improved hemostasis in combat casualties, decreasing blood loss by 23% (see Appendix C for more information on the use of rFVIIa). The use of this product should be reserved for those patients likely to require massive transfusion (e.g. significant injury and risk factors) and is at the discretion of the treating physician. It should be the judgment of the provider that the casualty has a life-threatening hemorrhage and coagulopathy. 1) Usual Dose: 100 mcg/kg intravenously; may be repeated in 20 minutes. 2) Contraindications: Active cardiac disease. 3) Storage: Refrigerate (2–8°C/36–46°F) prior to reconstitution and use. The FDA recently approved a room temperature stable product. This will be distributed throughout the USCENTCOM AOR as the current supplies are exhausted. ETA: I included the FVIIa guidelines for reference as well, and expect we'll see a lot less Novoseven use now with TXA being approved.