Background: Observational studies have suggested that accelerated surgery is associated with improved outcomes in patients with a hip fracture. The HIP ATTACK trial assessed whether accelerated surgery could reduce mortality and major complications. Methods:We randomised 2970 patients from 69 hospitals in 17 countries. Patients with a hip fracture that required surgery and were ≥45 years of age were eligible. Patients were randomly assigned to accelerated surgery (goal of surgery within 6 hours of diagnosis; 1487 patients) or standard care (1483 patients). The co-primary outcomes were 1.) mortality, and 2.) a composite of major complications (i.e., mortality and non-fatal myocardial infarction, stroke, venous thromboembolism, sepsis, pneumonia, life-threatening bleeding, and major bleeding) at 90 days after randomisation. Outcome adjudicators were masked to treatment allocation, and patients were analysed according to the intention-to-treat principle; ClinicalTrials.gov, NCT02027896. Findings:The median time from hip fracture diagnosis to surgery was 6 hours (interquartile range [IQR] 4-9) in the accelerated-surgery group and 24 hours (IQR 10-42) in the standard-care group, p<0.0001. Death occurred in 140 patients (9%) assigned to accelerated surgery and 154 patients (10%) assigned to standard care; hazard ratio (HR) 0.91, 95% CI 0.72-1.14; absolute risk reduction (ARR) 1%, 95% CI -1-3%; p=0.40. The primary composite outcome occurred in 321 patients (22%) randomised to accelerated surgery and 331 patients (22%) randomised to standard care; HR 0.97, 95% CI 0.83-1.13; ARR 1%, 95% CI -2-3%; p=0.71.Interpretation: Among patients with a hip fracture, accelerated surgery did not significantly lower the risk of mortality or a composite of major complications compared to standard care.

Since 1968, when Baxter and Shires developed the Parkland formula, little progress has been made in the field of fluid therapy for burn resuscitation, despite advances in haemodynamic monitoring, establishment of the 'goal-directed therapy' concept, and the development of new colloid and crystalloid solutions. Burn patients receive a larger amount of fluids in the first hours than any other trauma patients. Initial resuscitation is based on crystalloids because of the increased capillary permeability occurring during the first 24 h. After that time, some colloids, but not all, are accepted. Since the emergence of the Pharmacovigilance Risk Assessment Committee alert from the European Medicines Agency concerning hydroxyethyl starches, solutions containing this component are not recommended for burns. But the question is: what do we really know about fluid resuscitation in burns? To provide an answer, we carried out a non-systematic review to clarify how to quantify the amount of fluids needed, what the current evidence says about the available solutions, and which solution is the most appropriate for burn patients based on the available knowledge.

Patients with major burn injury undergo a series of pathophysiologic changes that begin with a systemic inflammatory response and coagulation abnormalities, similar to those experienced by patients with sepsis or severe trauma. Coagulation changes in patients with burns are generally characterized by procoagulant abnormalities, but alterations in fibrinolysis and anticoagulation factors have also been observed. Around 40% of patients with major burn show changes on standard coagulation tests, and these have been related to the severity of the lesions, smoke inhalation, and administration of intensive fluid resuscitation therapy. Current surgical techniques for debridement of burn lesions are aggressive and associated with considerable blood loss. A fast-acting selective enzymatic debriding agent based on bromelain has been recently developed. NexoBrid is indicated for removing eschar in adults with deep partial- and full-thickness thermal burns. A potential effect of oral bromelain on hemostasis has been described, but it is uncertain whether NexoBrid application has a clinically relevant impact in this regard. We present the clinical case of a patient with burns who showed a coagulation abnormality shortly after NexoBrid use.

Major burn patients (MBP) can present multifactorial coagulation alterations induced by trauma and endothelial damage, fluid replacement therapy, hypothermia, hypoperfusion, acidosis, and activation of the inflammatory cascade. However, the multiple coagulation alterations that occur are still poorly defined. The aim of this review is to combine the results of the different coagulation tests currently used to study coagulation changes in these patients. The PubMed database was searched for articles reporting factor levels or coagulation tests using the keywords "Burns" and "Blood Coagulation". Of the 720 articles retrieved from the search, 20 were finally included in the review. Coagulopathy in the MBP differs from that of the trauma patient, insofar as the former present with an increase in factors VIII, IX and vW on admission accompanied by an increase in fibrin and thrombin production. This is followed by activation of fibrinolysis and prolonged prothrombin (PT) and thromboplastin (aPTT) times in the first 24 hours, increased fibrinogen after 48 hours, and thrombocytosis between the second and third week. Viscoelastic testing shows a pattern that shifts from normal coagulation to a hypercoagulable state with no evidence of hyperfibrinolysis. Alterations in PT and aPTT together with elevated Factor VIII have been associated with mortality, while normalization of antithrombin, and protein C and S levels are associated with a good prognosis. Although standard coagulation tests initially show alterations, the MBP does not appear to be hypocoagulable, and viscoelastic testing shows a trend towards hypercoagulability over time. Coagulation disorders affect prognosis in the MBP.

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