Every year, the volume of published research continues to outpace capacity to consume. “Gotta catch ‘em all!” may be an appealing mantra, however it is impracticable to achieve with the medical literature. The Sisyphean task remains to try to keep up—and, in that vein—here is a light round of the emergency medicine literature from 2023.

How Best to Stop the Bleeding in Trauma?

All bleeding stops. The delicate trick is to stop the bleeding before the patient dies, while also simultaneously not tilting the coagulation cascade too far in the direction of excessive clotting.

The past decade has seen the ubiquitous rise of tranexamic acid (TXA), for use in nearly all types of bleeding. Many of the trials testing TXA, however, have been performed in low-resource settings, potentially limiting generalizability. The PATCH-Trauma trial took a critical look at TXA in major trauma in the advanced trauma systems of Australia and found a mixed result: a slightly greater number of patients were still alive six months following TXA administration, but there was no difference in survival with a good functional outcome.¹ Yet another typically narrow result to add to the body of evidence surrounding TXA.

Asking the question, “Wouldn’t it be better to get ahead of the curve, rather constantly play catch-up to replete factor derangement associated with major bleeding?” A trial tested whether it would be fruitful to pre-emptively infuse four-factor prothrombin concentrate complexes (PCCs).² The brief answer from the “PROAG” trial in France is “no.” Empiric PCC infusion was associated only with increased pro-thrombotic events without corresponding witnessed benefits. In a similar vein, “CRYOSTAT-2” tested whether routinely adding cryoprecipitate to massive transfusion protocols improved all-cause mortality.³ In this instance, there was neither benefit nor harm.

What’s New in Stroke Care?

Adding further to the body of literature telling us tenecteplase is an entirely valid alternative to alteplase, we have “TRACE-2.”⁴ Repeated trials have not shown alteplase to have any signal of better outcomes, nor tenecteplase to have an association with increased adverse events. TRACE-2 continues to demonstrate these observations. The simplicity of tenecteplase administration makes its use likely the preferred agent for treating acute ischemic stroke.

Tackling the age-old question: “we can administer thrombolytics to everyone, right?” the “ARAMIS” trial throws up another red flag for patients suffering mild stroke.⁵ In this randomized controlled trial enrolling patients with non-disabling stroke, dual antiplatelet therapy provided better outcomes for patients than thrombolytics, while avoiding excess symptomatic intracranial hemorrhage. These results do not generalize to mild, disabling stroke.