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Welcome To ResusNation #112
A City That Drowned in Molasses
On a chilly January afternoon in 1919, Boston’s North End was struck by an unthinkable disaster—not of fire, flood, or war, but of molasses. A 50-foot-tall steel tank holding more than 2 million gallons of the sticky syrup burst open without warning, unleashing a 25-foot wave of molasses through the streets at speeds exceeding 30 miles per hour. The wall of thick goo swept up everything in its path—people, horses, wagons, and buildings—flattening structures and trapping victims in a slow, suffocating tide. When the chaos subsided, 21 people were dead, more than 150 injured, and Boston had suffered one of the strangest tragedies in American history.
The “Great Molasses Flood,” as it came to be known, wasn't just bizarre—it was preventable. The tank had been poorly constructed, never properly tested, and overfilled in the days prior. The warm molasses mixed with the colder contents inside created expanding gas, and the pressure proved too much. Cleanup took weeks, with molasses clinging to cobblestones, walls, and even residents' shoes long after the disaster. For years, locals claimed you could still smell the sweetness on hot summer days. A century later, the flood serves as a cautionary tale: sometimes the most unexpected things can become catastrophic—especially when they're poorly built and full of sugar.
Why I Never Run a Code Without an A- Line
I believe an arterial line is absolutely essential for post-cardiac arrest patients, and I'll tell you why. First, it provides real-time blood pressure monitoring—I don't want to wait for a blood pressure cuff to cycle when seconds count. When I see pressure dropping, we can immediately ramp up vasopressors and adjust our resuscitation strategy. This immediate feedback loop has made a tremendous difference in my critical care practice.
The arterial line also gives us crucial data during resuscitation efforts. We can focus on maintaining adequate diastolic pressure, which approximates coronary perfusion pressure—if it's below 30, we know we need to improve chest compressions or increase our efforts. And during rhythm checks, instead of wasting precious time feeling for pulses, I simply glance at the monitor for an arterial waveform. No tracing means no pulse, allowing us to minimize interruptions and get back to compressions faster. This approach has streamlined our code responses significantly.
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Andexanet vs. PCC: What You Need to Know About Reversing Brain Bleeds
Patients with acute intracerebral hemorrhage who are receiving factor Xa inhibitors face significant risks of hematoma expansion and poor outcomes. The ANNEXA-I randomized trial compared andexanet alfa, a specific reversal agent that binds and sequesters factor Xa inhibitor molecules, with usual care (primarily prothrombin complex concentrate) in 452 patients with factor Xa inhibitor-associated intracerebral hemorrhage. The primary finding was that andexanet resulted in significantly better hemostatic efficacy than usual care (67.0% vs. 53.1%, adjusted difference 13.4 percentage points, p=0.003), primarily driven by superior control of hematoma expansion.
The study demonstrated andexanet's mechanistic advantage with a 94.5% median reduction in anti-factor Xa activity compared to only 26.9% with usual care. However, this hemostatic benefit came at a cost - thrombotic events occurred in 10.3% of andexanet patients versus 5.6% with usual care (p=0.048), with ischemic stroke being particularly concerning (6.5% vs. 1.5%). Despite better control of bleeding, there were no significant differences in 30-day mortality or functional outcomes measured by the modified Rankin scale. The findings suggest that while andexanet provides superior reversal of anticoagulation and better control of hematoma expansion, clinicians must carefully weigh this benefit against the increased thrombotic risk when selecting reversal strategies.
Here's my Takeaways:
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Finding: 67.0% of andexanet patients achieved hemostatic efficacy (≤35% hematoma expansion) versus 53.1% with usual care (p=0.003)
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Practice Impact: Consider andexanet for better bleeding control in factor Xa inhibitor-associated brain hemorrhage, but with vigilance for thrombotic events
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Population: Primarily elderly patients (mean age 79) with atrial fibrillation taking apixaban, rivaroxaban, or edoxaban who developed intracerebral hemorrhage
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Limitation: Despite better hemostatic control, andexanet nearly doubled thrombotic events (10.3% vs 5.6%) with no improvement in 30-day functional outcomes
Want to hear more about it? Listen now as we break down the findings that have the medical community buzzing. Click on the podcast below to dive into this game-changing research.
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Want to learn more? Read the full study "Andexanet for Factor Xa Inhibitor–Associated Acute Intracerebral Hemorrhage" by Connolly SJ, Sharma M, Cohen AT, et al. in N Engl J Med. (2024)
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- Qasim on "Getting to the Heart of the Matter: Breaking Down the Resuscitative Thoracotomy"
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