Background Tranexamic acid reduces surgical bleeding and reduces death due to bleeding in patients with trauma. Meta-analyses of small trials show that tranexamic acid might decrease deaths from gastrointestinal bleeding. We aimed to assess the effects of tranexamic acid in patients with gastrointestinal bleeding. Methods We did an international, multicentre, randomised, placebo-controlled trial in 164 hospitals in 15 countries. Patients were enrolled if the responsible clinician was uncertain whether to use tranexamic acid, were aged above the minimum age considered an adult in their country (either aged 16 years and older or aged 18 years and older), and had significant (defined as at risk of bleeding to death) upper or lower gastrointestinal bleeding. Patients were randomly assigned by selection of a numbered treatment pack from a box containing eight packs that were identical apart from the pack number. Patients received either a loading dose of 1 g tranexamic acid, which was added to 100 mL infusion bag of 0•9% sodium chloride and infused by slow intravenous injection over 10 min, followed by a maintenance dose of 3 g tranexamic acid added to 1 L of any isotonic intravenous solution and infused at 125 mg/h for 24 h, or placebo (sodium chloride 0•9%). Patients, caregivers, and those assessing outcomes were masked to allocation. The primary outcome was death due to bleeding within 5 days of randomisation; analysis excluded patients who received neither dose of the allocated treatment and those for whom outcome data on death were unavailable. This trial was registered with Current Controlled Trials, ISRCTN11225767, and ClinicalTrials.gov, NCT01658124.

Snake bite incidence is highest in Asia and sub-Saharan Africa. This retrospective audit of 533 adult patients, who had presented to the Emergency Department, collates clinical features, effect of pharmacologic interventions and the risk factors that influence morbidity and mortality. Dual toxicity, neurological and haematological, was observed in 30.4% of patients. Laboratory evidence of haematotoxicity was demonstrated in 314 (58.9%) and 40% demonstrated clinical evidence of bleeding. However, 7.3% of these patients did not have laboratory evidence of bleeding disorder (p < 0.001). Conversely, 60% did not have clinical evidence of bleeding, but demonstrated laboratory evidence of abnormal parameters. Acute kidney injury (AKI) was evident in 28% of patients and 15.3% required haemodialysis. About 25% with no haematotoxicity showed evidence of AKI. The majority received 6-12 vials of poly-valent anti-snake venom. Hypersensitivity reaction rate was 8% and predominantly anaphylactoid in nature. The length of hospital stay ranged from 2 to 28 days and 20% required mechanical ventilation. Overall mortality rate was 7.5% with significant association to AKI, haematotoxicity and assisted ventilation. The mortality rate was 18% in patients with pre-hospital delay more than 24 h, as against 5% when admitted within the above specified period (p = <0.001). The strength of this study is the accrued information of over a period of 10 years of snake-bite management through the Emergency Department of a university hospital setting. The limitations are the retrospective study design and the rejection percentage of 15.5% due to insufficient information from the total chart pool.

Despite significant increase in pseudocholinesterase levels with FFP, this pilot study did not demonstrate favorable trends in clinical outcomes with FFP or albumin.

The largest democracy on earth, the second most populous country and one of the most progressive countries in the globe, India, has advanced tremendously in most conventional fields of Medicine. However, emergency medicine (EM) is a nascent specialty and is yet to receive an identity. Today, it is mostly practised by inadequately trained clinicians in poorly equipped emergency departments (EDs), with no networking. Multiple factors such as the size of the population, variation in standards of medical education, lack of pre-hospital medical systems and non-availability of health insurance schemes are some of the salient causes for this tardy response. The Indian medical system is governed by a central, regulatory body which is responsible for the introduction and monitoring of all specialties--the Medical Council of India (MCI). This organisation has not recognized EM as a distinct specialty, despite a decade of dogged attempts. Bright young clinicians who once demonstrated a keen interest in EM have eventually migrated to other conventional branches of medicine, due to the lack of MCI recognition and the lack of specialty status. The Government of India has launched a nationwide network of transport vehicles and first aid stations along the national highways to expedite the transfer of patients from a crash site. However, this system cannot be expected to decrease morbidity and mortality, unless there is a concurrent development of EDs. The present article intends to highlight factors that continue to challenge the handful of dedicated, full time emergency physicians who have tenaciously pursued the cause for the past decade. A three-pronged synchronous development strategy is recommended: (i) recognise the specialty of EM as a distinct and independent basic specialty; (ii) initiate postgraduate training in EM, thus enabling EDs in all hospitals to be staffed by trained Emergency physicians; and (iii) ensure that EMs are staffed by trained ambulance officers. The time is ripe for a paradigm shift, since the country is aware that emergency care is the felt need of the hour and it is the right of the citizen.

Working dimensions are smaller in the Indian group compared with western publications. Endotracheal tubes ranging from size 3.0 to 6.0 might be used for cricothyroidotomy in the adult south Indian population.