Final fetch lengths for each examined direction in a future ice-free Arctic.
\\n\\n
More than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\\n\\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\\n\\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\\n\\nAdditionally, each book published by IntechOpen contains original content and research findings.
\\n\\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\\n\\n\\n\\n
\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'
Simba Information has released its Open Access Book Publishing 2020 - 2024 report and has again identified IntechOpen as the world’s largest Open Access book publisher by title count.
\n\nSimba Information is a leading provider for market intelligence and forecasts in the media and publishing industry. The report, published every year, provides an overview and financial outlook for the global professional e-book publishing market.
\n\nIntechOpen, De Gruyter, and Frontiers are the largest OA book publishers by title count, with IntechOpen coming in at first place with 5,101 OA books published, a good 1,782 titles ahead of the nearest competitor.
\n\nSince the first Open Access Book Publishing report published in 2016, IntechOpen has held the top stop each year.
\n\n\n\nMore than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\n\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\n\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\n\nAdditionally, each book published by IntechOpen contains original content and research findings.
\n\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\n\n\n\n
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An international group of distinguished contributors have covered particular aspects and the book includes optimization of semiconductor laser diode parameters for fascinating applications. \nThis collection of chapters will be of considerable interest to engineers, scientists, technologists and physicists working in research and development in the field of semiconductor laser diode, as well as to young researchers who are at the beginning of their career.",isbn:null,printIsbn:"978-953-51-0549-7",pdfIsbn:"978-953-51-4996-5",doi:"10.5772/1999",price:139,priceEur:155,priceUsd:179,slug:"semiconductor-laser-diode-technology-and-applications",numberOfPages:390,isOpenForSubmission:!1,hash:"67c029e3a582411c5f9ab3a7dc28884f",bookSignature:"Dnyaneshwar Shaligram Patil",publishedDate:"April 25th 2012",coverURL:"https://cdn.intechopen.com/books/images_new/1532.jpg",keywords:null,numberOfDownloads:58399,numberOfWosCitations:29,numberOfCrossrefCitations:5,numberOfDimensionsCitations:17,numberOfTotalCitations:51,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"May 2nd 2011",dateEndSecondStepPublish:"May 30th 2011",dateEndThirdStepPublish:"October 4th 2011",dateEndFourthStepPublish:"November 3rd 2011",dateEndFifthStepPublish:"March 2nd 2012",remainingDaysToSecondStep:"10 years",secondStepPassed:!0,currentStepOfPublishingProcess:5,editedByType:"Edited by",kuFlag:!1,biosketch:null,coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"106345",title:"Prof.",name:"Dnyaneshwar",middleName:"Shaligram",surname:"Patil",slug:"dnyaneshwar-patil",fullName:"Dnyaneshwar Patil",profilePictureURL:"https://mts.intechopen.com/storage/users/106345/images/2754_n.jpg",biography:"Dr. D. S. Patil has been graduated from Poona University with a rank. He received the M.Sc. degree in Electronics Science with a first class in 1986 from the Poona university department of Electronics-Science. He secured M.C.M. degree with A+ grade from Poona University and the Ph.D. degree in Electronics from the North Maharashtra University, Jalgaon [Maharashtra], India. He qualified state eligibility test in Electronics in 1995. Since 1991, he has been working in the North Maharashtra University, Jalgaon and presently working as a Professor. He secured high school scholarship, national merit scholarship and received Rashtriya gaurav award sponsored by India International Friendship Society. He successfully completed a major Young scientist project from Department of Science and Technology, India. His name has been considered in the Steering committee as a member for the International Conference on Nanoscience and Technology 2008, Colarado, United States of America, International vacuum Congress, China 2010. He worked on the various committees of the universities. He has published about 157 papers in reputed journals and proceedings of the conferences. His research interests include the computer simulation of semiconductor, nano and optoelectronics devices, nano-electronics, Materials development and characterization for the nano-technological and optoelectronics applications, process automation using advanced microcontrollers and embedded systems, organic electronics and computer simulation of nanostructures including quantum dots and superlattice. He has developed with his research student a novel model of probability density spreading in GaN quantum wells. He has developed with research students, computer controlled dip coating system and microcontroller based spin coating system for the deposition of nano-materials. He has guided many students for their innovative research. He visited France and Germany to attend international conferences and present his papers. Moreover, he visited Technical University, Zurich, Switzerland to know the various activities and research carried out in Electronics Technology department. He worked as a reviewer for many reputed international journals. He has delivered many invited talks and popular lectures. He developed the Electronics Practical laboratory and curriculum as a first member of Electronics Department and framed syllabus of M.Phil. (Electronics) and M.Sc.(Electronics). Despite of this, he taught various courses to M.Tech. (VLSI Technology), M.C.A and B.Tech.(Chemical Technology). Recently, his name has been considered in Marscue Who’s who in the world.",institutionString:null,position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"0",totalChapterViews:"0",totalEditedBooks:"1",institution:{name:"North Maharashtra University",institutionURL:null,country:{name:"India"}}}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"1226",title:"Optoelectronics",slug:"optics-and-lasers-optoelectronics"}],chapters:[{id:"35899",title:"Effect of Cavity Length and Operating Parameters on the Optical Performance of Al0.08In0.08Ga0.84N/ Al0.1In0.01Ga0.89N MQW Laser Diodes",slug:"effect-of-cavity-length-and-operating-parameters-on-the-optical-performance-of-al0-08in0-08ga0-84n-a",totalDownloads:3587,totalCrossrefCites:0,authors:[{id:"104427",title:"Dr.",name:"Alaa J.",surname:"Ghazai",slug:"alaa-j.-ghazai",fullName:"Alaa J. 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H.",surname:"Shahine",slug:"m.-h.-shahine",fullName:"M. H. 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Predeep"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"63239",title:"Coastal Erosion Due to Decreased Ice Coverage, Associated Increased Wave Action, and Permafrost Melting",doi:"10.5772/intechopen.80604",slug:"coastal-erosion-due-to-decreased-ice-coverage-associated-increased-wave-action-and-permafrost-meltin",body:'\n
The Arctic physical environment is characterized by various dynamic phenomena, sudden ones, like polar lows and unexpectedly strong storms, or time developing and periodical, like gradual coastal erosion of the shoreline. In order to operate safely in this environment, one needs to be undoubtedly supported by daily weather forecasting and monitoring. However, accurate means of doing so and good prognostics are challenged by the lack of historical and scientific data as well as a limited number of stations for data collection, which make the Arctic Ocean a hazardous environment with challenging marine and weather conditions.
\nRecent events testify the aforementioned hazardousness. For example, on July 24, 2010, in the Varandey area in northern Russia, the oil treatment and storage terminal located kilometers inland was flooded and the airport runway closed, due to the fact that the coast was severely damaged by excessive flooding. This flooding event was the outcome of combined storm waves, surges, and tides. Other northern production sites, such as the Northstar artificial oil and gas production island in the Beaufort Sea, have also been damaged by significantly high waves. In that case during the design phase, the facilities, which are located 19 km northwest of Prudhoe Bay, Alaska and 10 km north of the Alaskan coast at a water depth of 10 m, were designed using historical data and assumptions of fetch length and wave height occurrence which did not correspond to events that happened some years after production startup.
\nIn this chapter, we are analyzing some of these challenges and phenomena, taking into consideration the significant changes that have occurred in the Arctic area during the last decades. For instance, throughout the years, the average monthly Arctic sea ice extent has dropped dramatically from 12.5 million km2 in 1980s to about 10.8 million km2 in 2016, showing a declining trend of 4.1% per decade (see Figure 1) [1]. This means that at coastlines and areas that before used to be covered by snow permanently, people now observe waves up to 4 m in height. Due to the retraction of the ice cover, new paths for trading and transportation are seasonally opened, like the North Sea Route (the Northeastern Passage), which is now used as a transport path with ships for liquefied natural gas (LNG) from the Sabetta LNG facilities on Yamal to the Chinese market. During the summer period and early autumn, when the passage is almost ice free, operators can travel from Europe to Asia using this path to the north of Russia with the service of icebreakers.
\nMonthly June Arctic sea ice extent for 1979–2018 shows a decline of 4.1% per decade [1].
The wave forces that are generated due to the ice-free surface enhance the ice shrinkage and reduce the ice thickness, helping ice edges to detach more easily from the main ice core. Another observation is the increase of the temperature and seasonal record peaks that might be also a consequence of the annual shrinkage of the permanent ice extent which works as natural mirror and shield against the heat. The increase of the temperature does consequently lead to increased ice melting creating a loop of domino effects.
\nAll the aforementioned changes testify to a likely future situation where ice surface will shrink further and possibly occasionally disappear. Shipping and operations in the area will face a different environment of what they are designed for today. Some new challenges might occur. As long as waves are considered, it is probable that assets will face a more hazardous environment with higher waves generated in an open ocean. Some business people might claim that conditions will be more favorable for operations in the Arctic if temperature increases, since this will alleviate winterization issues. However, no one can predict with certainty what the environmental conditions will be and how the aforementioned changes will influence the phenomena by reducing or increasing some risks.
\nIn relation to the definition of the risk of an activity, A, is the multi-dimensional combination of its probability P, its consequences, C, and the related uncertainties, U, of what the outcome will be (A, P, C, and U). The uncertainty of the activity is well linked to the knowledge that one has about the activity. Therefore, since in the Arctic area there is lack of knowledge due to scarce historical data or measurements of previous hazardous events for a sufficient long period, risks can be considered inherently high in the Arctic area where safety for the assets or humans may not be guaranteed.
\nThus, there is a need to understand better the challenges that might occur in the future by assessing some potential future scenarios. One such scenario is an open Arctic Ocean where there is no ice. In this chapter, this scenario is related to the potential increase of the wave height in specific areas. One specific method for predicting maximum wave heights is used, here, covering the subject briefly and giving food for further research and analysis.
\nWinds blowing over the sea generate ocean surface waves (wind-sea and swell) which are related to the distance (length of fetch) and the duration of wind. As both wind-sea and swells depend on the open water sea fetch, further reductions in seasonal ice cover will result in larger waves [2].
\nSuch larger waves can have multiple consequences to the coasts around but also to the marine operations in the area. Wave activity when reaching the shallow areas along the coast leads to currents and water circulation that can cause excessive erosion and enhanced sediment transportation. Also, present navigation experience can be challenged due to higher waves generated by rapid storms and changing seafloor conditions. In the future Arctic Ocean, wave conditions like those will be changing the known environment for nature and humans.
\nMoreover, the existence of ice on the sea surface makes the phenomenon of wave and ice interaction complex. Ice masses suppress waves, diminishing them, but also waves alter and influence the thickness and the growth of the ice. Waves start penetrates more and more into the weakened sea-ice reaching the marginal ice zone, the part of the ice cover that interacts with the open ice-free ocean. This loop produces a positive feedback that could accelerate the loss of ice especially during summer and early fall [3] (Figure 2).
\nFeedback loop of the wave ice interaction.
As mentioned before, the aim of this chapter is not to execute an excessive assessment of the ice melting impact on the design wave heights, but rather stress and highlight the challenge that might occur in a worst-case scenario when there is no ice in the Arctic. In this way, one can have a better understanding of the magnitude of change that could be expected. These effects are also present, possibly in a less extend and locally, when there is a partial reduction of the ice surface and not total disappearance.
\nThe methodology chosen is based on the assumption that the Arctic Ocean in a free-ice period can be considered as a gigantic ocean, surrounded by the northern coasts of the neighboring countries. When one aims to estimate the characteristic wave height, two factors are the main contributors that need to be taken into consideration. One is the fetch length, the length of water over which a given wind can blow, and this is also the main factor that creates storm surge which also leads to coastal erosion and flooding. The other factor is the wind characteristics, such as duration and velocity. Thus, focus initially was given on areas that have the longest potential fetch distance, assuming that the wind conditions (duration and speed) are similar from all directions.
\nTaking all the aforementioned factors into consideration and also the available data and their quality, the northern part of Svalbard Island is chosen to be examined. As per now, this part of the Arctic region is covered by ice during most of the year, but in a free ice future scenario, long fetches are revealed that can potentially generate high waves. Moreover, statistical studies have showed that the percentage of north easterly winds occurring annually at the examined area is significant which testifies the relevance of the choice of location and direction for the study. Five different meteorological stations at the north and northeast area of Svalbard are selected to acquire the desired wind data. These data are analyzed to extract information regarding the most extreme wind incidents and storms from 2000 to 2014. The collected data refer to the early fall period of the year (September and October), as this is the period when the Arctic is expected to have the lowest ice percentage.
\nThe stations are as follows [4]:
KARL XII (99935): Latitude: 80.653, Longitude: 25.008
KONGSØYA (99740): Latitude: 78.9277, Longitude: 28.892
VERLEGENHUKEN (99927): Latitude: 80.059, Longitude: 16.25
KVITØYA (99938): Latitude: 80.07, Longitude: 31.5
HOPEN (99720): Latitude: 76.5097, Longitude: 25.0133
Since the main focus of this study is to examine the difference in wave height estimates due to the shrinkage of ice coverage, the directions that are examined are those that showed the most dramatic change in length. Thus, for the examined area, the directions that are chosen are all between 320 and 55o. As shown in Figure 3, in the case of ice coverage disappearance, the increase of the fetch length in some directions is up to three times longer than the one today (from presently 500 to 2000 km to the northern coast of Russia and from 200–250 to 1500–3000 km to the coasts of Canada and Alaska).
\nPresent maximum and minimum available fetch lengths north of Svalbard during early autumn periods (left). Future fetch lengths available in a free ice Arctic Ocean, between 320 and 55° in steps of 2.5°.
The calculation of the maximum characteristic wave height is made by using the Jonswap method. This method is chosen as it is judged appropriate for open sea waves and considers the influence of the fetch length. According to this method, a wind generated wave can be either fetch limited (limited by the available distance over which it has been generated) or duration limited (limited by the period of time that the wind is blowing).
\nIn order to find the largest wave height that can occur due to the wind phenomena in the region, all the characteristic significant waves, Hs, for the directions of interest were assessed. In Svalbard, the examined directions were NNW, N, and NNE (North-Northwest 340°, North 0°, and North-Northeast 32.5°). Those directions were chosen because we wanted to cover as much as we could of the examined area for three different directions. For that reason, straight lines were drawn for each 2.5° with the use of maps from Google Earth (see Figure 3) until the opposite coasts were reached.
\nFor each and every one of the three wind directions that were examined (NNW, N, and NNE), wind was assumed from an angle of 45°, that is, from −22.5 to +22.5o for each direction (usually the spreading used is 90°, but here, because of the limited examined area, we had to choose a smaller and more narrow area, the half). The fetch length, F, was drawn for every αi = 2.5° angle around each direction, and they are calculated by the following quation [5]:
\nwhere N is the number of each fetch line drawn between −22.5 and + 22.5° for each of the three directions (NNW, N, and NNE).
\nThe examined directions were chosen based on the morphology of the area; the islands and coasts of Greenland at the northwest part, for example, do not allow the development of long enough fetches to be considered.
\nAs long as the wind duration is considered, it is important to mention, here, that it would have been reasonable to have data with annual percentage of occurrence for each wind velocity in each direction. However, such data were not available; therefore, all the calculations are performed for specific events collected by the five stations over the past 15 years. So, for every fetch direction, one average wind speed is calculated. This means that every storm observed in the data is related to the three main directions (NNW, N, and NNE), and a mean wind velocity is calculated which is used to describe the wind at 10 m altitude.
\nSteps of the Jonswap method [5]:
\nStep 1. Calculation of the frictional wind velocity
\nwhere W = mean velocity at 10 m height.
\nStep 2. Calculation of the equivalent fetch, Feq, depending on the duration of the wind:
\nwhere g = gravity acceleration, 9.81 m/s2; td = the duration of the wind blowing; Feq = the equivalent fetch length.
\nStep 3. Checking whether the wave is duration or fetch limited:
If Feq > F, then the wave is fetch limited, and the fetch, F, of the specific direction (Eq. (1)), needs to be used for the calculation of the characteristic height, Hs.
If Feq < F, then the wave is duration limited, and the Feq should be used for the height calculation.
Step 4. Calculation of the characteristic wave height
\nHs = characteristic wave height.
\nStep 5. Calculation of the characteristic period of the wave
\nTs = characteristic wave period.
\nBased on the previous methodology, the results of the calculation are as shown below. Table 1 is showing the maximum possible fetch distances, as calculated using Eq. (1). This fetch is as expected in the case of an ice-free Arctic Ocean. Based on the aforementioned available fetch, the significant height of the waves together with the characteristic wave period was calculated and shown in Table 2.
\nFinal fetches for each direction | \n|
---|---|
Direction | \nFetch F (km) | \n
North-Northeast | \n2661 | \n
North | \n3130 | \n
North-Northwest | \n2494 | \n
Final fetch lengths for each examined direction in a future ice-free Arctic.
Significant wave height and characteristic period | \n|||||||
---|---|---|---|---|---|---|---|
Wind direction | \nW (m/s) | \ntd (hours) | \nu* | \nFeq (km) | \nComment | \nHs (m) | \nTs (s) | \n
NNW | \n16.60 | \n90 | \n0.68 | \n630.51 | \nDuration limited | \n7.13 | \n11.12 | \n
N | \n11.38 | \n102 | \n0.44 | \n2418.72 | \nDuration limited | \n9.03 | \n14.94 | \n
NNE | \n14.55 | \n36 | \n0.58 | \n2307.72 | \nDuration limited | \n11.70 | \n16.20 | \n
Final wave significant heights and characteristic periods in a future ice free Arctic.
Since the aim of the chapter is to compare the waves of the future ice-free scenario with those of today, wave characteristic heights based on current conditions are calculated and shown in Table 3.
\nSignificant wave height and characteristic period | \n|||||||
---|---|---|---|---|---|---|---|
Wind direction | \nW (m/s) | \ntd (hours) | \nFetch (km) | \nFeq (km) | \nComment | \nHs (m) | \nTs (s) | \n
NNW | \n16.60 | \n90 | \n160 | \n630.51 | \nFetch limited | \n3.59 | \n11.12 | \n
N | \n11.38 | \n102 | \n150 | \n2418.72 | \nFetch limited | \n2.25 | \n14.94 | \n
NNE | \n14.55 | \n36 | \n350 | \n2307.72 | \nFetch limited | \n4.52 | \n16.20 | \n
Final wave significant heights and characteristic periods in today’s conditions.
All in all, the results show a significant increase of the height in the case of an ice-free Arctic Ocean. Actually, since the waves were duration limited, it is possible that such waves can be generated even with some permanent ice coverage. In detail, in the NNW direction, the wave height was almost doubled, from 3.59 to 7.13 m. In the North direction, the most significant change is observed with more than three times magnification of the characteristic height, from 2.25 to 9.03 m. Last, in the NNE direction, the prediction shows an increase from 4.52 to 11.70 m.
\nThe examined scenario of ice retraction should not be considered as topical only in the Svalbard area. Many measurements and experimental campaigns have been made in the eastern part of the Arctic Ocean, close to Beaufort Sea, where the sea ice cover has retreated significantly. Due to this dramatic retreat, especially in September 2012, 5 m height waves were observed in the middle of the basin. These were extremely large waves compared to what has been observed previously, testifying the assumption and the prediction of wave height enhancement due to ice surface shrinkage [2].
\nApart from experimental campaigns and measurements, other studies using prognostic models have shown significant changes in estimated wave heights. These changes are undoubtedly linked to the increase of the fetch length created by the free-ice sea area. What is worth mentioning here is that the results showed also a rise in surface winds in the Arctic area, mainly in Kara, Laptev, and East Siberian Seas. On the contrary, at the western part of the Arctic region, in the Barents Sea, a drop of the winds and consequently the wave heights were observed [6].
\nMoreover, research supports the assumption that in areas where the ice coverage is shrinking, the wave phenomena will change. Results have shown a growth in wind speeds and an increase of the frequency of occurrence of waves of 2 m height. On the other hand, the same studies have shown that the change in extreme wave heights is marginal. The areas where the change is more significant are those of the northern parts of Barents Sea, Kara, and Chukchi Seas, whereas, in areas where the sea is already ice free during September and October, like the North Atlantic and the main part of the Barents Sea, extreme waves would be less frequently witnessed and great changes in extreme wave heights could not be expected [7]. In conclusion, the eastern Arctic regions and areas close to the north Canadian coasts will be influenced most by the absence of the ice [6].
\nIt should be noted that the discussion above relates to wave heights only. To estimate the sea level during a storm surge in the case of wind in direction toward shore has been outside our scope. A storm surge that encounters a shallow shore could climb up the coast easily, causing floods and increased erosion, while a storm surge that approaches a steep shore is more likely to break early, thus, cliff or steep shore might be sufficient obstacle to prevent a storm surge from piling-up and reaching far inland. The combined storm surge and waves will cause flooding and damages far inland. An unprecedented amount of erosion could occur due to the effect of flooding and wave action, in particular, as higher temperatures cause the increased melting of permafrost along the shores, these effects will be discussed below.
\nWarmer climate and rising temperatures affect the Arctic in many aspects. Thawing permafrost is of the phenomenon that is detected in the Arctic. Measurements over long periods of time show that the permafrost temperature has rose by up to 2°C, and shallow permafrost layers in some areas have thawed completely. Consequently, the permafrost extent has shrunk by 30–80 km in Russia and up to 130 km in Canada [8]. In addition, a decrease in the snow cover creates a feedback mechanism of increasing temperatures. These phenomena lead to unstable grounds and emissions of greenhouse gases and toxicants that had been encapsulated in the frozen ground, and the permafrost is thawing in areas which were permanently frozen until recently [9]. The Arctic shores easily erode when hit by storm surges and strong waves. As a result of melted materials being washed away, the shore becomes even more susceptible to erosion [10].
\nThe permafrost’s thermal properties, conductivity, heat capacity, thermal diffusivity, latent heat, and thermal expansion, are among the key variables in determining permafrost melting and erosion rate. The thawing rate of a given soil depends on the soil composition (soil particles, ice, water, and air content of the soil) and the conditions of the physical environment. By knowing the content of frozen water in the ground and combining it with the assumptions that:
Ice melts at temperatures above 0°C.
The soil’s thawing temperature is 0°C.
All melted ground will wash away and erode by the impact of storm surge and waves.
An important parameter is the Degree days, the product of temperature and number of days. The degree days for an average temperature of 3°C over a period of 7 days is, for example, 3·7 = 21°C·d. The thawing index (Ist) is the number of degree days where the temperature is above the melting temperature (for water, 0°C). To calculate Ist, the degree days of each month were calculated: a monthly average temperature was calculated and multiplied by the number of days in each month. Under the assumption that the soil melting temperature is 0°C, Ist of the soil is the summation of degree days above 0°C for a one-year period.
\nThe thermal models for coastal erosion that we used are described in [11]. For thawing depth estimation, first an evaluation of the permafrost soil consistency (soil profile and water content) was made, and then we were using the Stefan’s equation (see [9, 10, 11]) to estimate the thawing depth in a partly frozen soil.
\nSeveral assumptions were made for estimating the amount of eroded soil during the one year period:
Erosion occurs between May and September (the erosion process is negligible between October and April, due to sea ice and frozen soil).
A big storm surge hits the shores at the end of each season (Spring, Summer, and Autumn) and erodes all melted soil.
A season would count as a 50-day period.
As the average erosion rate in Varandey area was 2.7 m/year between 2005 and 2007 [11], based on these assumptions, the amount of eroded soil could be estimated.
\nThe assumption that all melted material is being removed by a storm surge at the end of each “season” means that a new frozen soil layer is now exposed to heat and melting processes. A melted soil layer that stays intact could create an insulation layer that prevents heat penetration and decreases the melting processes, so the overall melted and eroded soil amount would be much smaller. For example, a single storm surge that hits the shore at the end of fall would hardly influence the erosion rate.
\nAn erosion rate sensitivity analysis was made to assess and better understand the effect of the number of storms in a year on the total erosion rate. Three different cases of storm surge were examined: the period between May and September was divided into sub-periods. It was then assumed that a storm surge hits the shore at the end of each sub-period and erodes all melted material.
\nAs can be seen in Figure 4, the results correspond to the expectations—the erosion rate is increased as the number of storms rises. This result is further detailed in Figure 5, which shows the total erosion as number of storms/storm surges.
\nThe effect of number of storms on the total erosion as a function of time [10].
Total erosion as a function of number of storm surges [10].
Undoubtedly, people and operations are facing extreme challenges in the Arctic Ocean. From polar lows and sudden storms to icing and iceberg drifts. However, more and more often, people are coming across extreme waves and permafrost erosion to an extent that has never been witnessed before. One of the reasons of this change is believed to be the melting of the ice and the alteration of the physical environment in the Arctic area. Wind blows over larger areas of the sea surface which consequently leads to more extreme wave phenomena and coastal erosion. Additionally, the increase of the annual average temperature and the prolongment of the warm periods influence the aforementioned phenomena which consequently lead to an increasing coastal erosion.
\nIn this chapter, it is shown how such an ice shrinkage can influence the development of the waves by increasing the fetch length that will generate the examined waves. Additional research supports the aforementioned assumption, since measurements have testified that increase of the wave heights in areas where the waves were relatively mild. Of course, the outcomes from such research activities vary and further studies are needed to get a better view of the situation. What one can be certain of, though, is that permanent ice surface shrinkage will create a different wave and wind environment in the Arctic area. It is hard to say which of these factors will be the dominant and influence more significantly the situation.
\nThe consequences of higher storm surge levels and higher waves and increased wave forces can be unpredictable. For instance, for already existing oil and gas platforms, which were designed according to historical data, unknown wave phenomena can, irreversibly, threaten human lives and assets. Therefore, in the case of higher waves, operators need to execute a reassessment of the air gap of the platform to avoid deck slamming; likewise, the strength of structures and safety factors should be reconsidered by including the uncertainties generated by the physical environment.
\nDue to increased wave action and melting of permafrost, Arctic coastlines and coastal infrastructure would see an increased stress from enhanced erosion and sediment circulation when sediment transportation along the coast alters.
\nIn practice, newly opened Arctic seas will boost and encourage trading and navigation in the region since they will provide new paths with significant economic benefits. Shipping and offshore activities in areas which today we struggle to develop would be possible, but uncertainties related to storms and associated waves will remain, unless further studies are not made. Hazards that occur in open oceans might occur in the Arctic as well. For example, such hazards could be tsunamis, generated by earthquakes and motions of the seabed.
\nThese are some examples of threats that so far were sleeping in the sea under the permanent ice coverage. Now, with its excessive melting, all these threats start coming on to the surface, putting in danger coastlines, people, and operations in the region.
\nThe first author would like to thank Dr. Athanassios A. Dimas, Professor in the Department of Civil Engineering at the University of Patras, for clarifying uncertainties during the research.
\nControl of bleeding wounds has always been a priority in managing injured patients, and providers have used numerous adjuncts to staunch bleeding for decades, with variable success. The earliest use of topical hemostatic agents dates from the end of the nineteenth century when thrombin was used by boxers and barbers to control bleeding from lacerations [1]. Almost a century before the clotting cascade was completely elucidated, in 1909 Bergel had described using topical fibrin to stop surgical bleeding [2, 3, 4]. Subsequently, surgeons utilized fibrinogen in plasma as well as bovine thrombin to assist in a variety of surgical scenarios, including nerve repair and skin grafting [5, 6]. Commercial products first became available in Europe in 1972, but the Food and Drug Administration did not approve fibrin sealants in the United States until 1998 [3]. Over the course of time, numerous other types of hemostatic agents have been developed, each unique in their load bearing capacity, biomechanical properties, handling, derivation, and application [7].
Cutaneous and mucous membrane bleeding are common presentations to emergency departments. Data from the National Hospital Ambulatory Medical Care Survey in 2002 estimated that there were 7.27 million emergency department visits for lacerations, representing approximately 6.6% of all emergency department visits [8], and data from HCUP National Emergency Department Survey in 2013 estimated about 7 million emergency department visits or 5.2% of all visits for lacerations [9]. There are no data to quantify how many of these visits are associated with uncontrolled or major bleeding. The mainstays of treating bleeding remain the simple application of direct pressure with a pressure bandage and application of tourniquet if hemostasis is unable to be obtained. However, there are times that application of hemostatic agents can assist in bleeding control. In the modern era, with widespread use of anticoagulant and antiplatelet agents, as well as physiologically induced coagulopathies from liver disease and uremia, development of topical hemostatic agents to assist in terminating complex bleeding scenarios has become important.
We will briefly review classes of tissue adhesives, topical hemostatic agents, and the best practice data regarding each in the setting of the emergency department. We will provide common clinical bleeding scenarios and the application of these materials in those situations.
Topical hemostatic agents generally fall into one of two categories: the physical agents that work by providing a physical substrate which promotes hemostasis and the biologically active agents that enhance coagulation at the site of action(Table 1). In the emergency department, topical hemostatic agents are primarily used as adjuvant therapy to direct pressure to stop persistent bleeding from lacerations and abrasions that are not amenable to suture control, such as distal fingertip avulsions, flap lacerations with avulsion of the flap, and skin tears in the elderly. As well, topical hemostatic agents can be used to assist with persistent bleeding from nasal mucosa, gingival tissue after tooth extraction, and from vascular bleeding sites such as persistently bleeding dialysis access sites or bleeding lower extremity varices.
Product | Manufacturer | |
---|---|---|
Physical matrix topical hemostatic agents | ||
Gelatin matrix | Gelfoam® | Pfizer Inc., New York, NY, USA |
Surgifoam® | Ethicon Inc., Somerville, NJ, USA | |
Floseal® | Baxter International, Deerfield, IL, USA | |
Oxidized regenerated cellulose | Surgicel® | Ethicon Inc., Somerville, NJ, USA |
SafeGauze® | Medicom, Montreal, QC, Canada | |
Microporous polysaccharide spheres | Arista® AH | CR Bard Inc., Murray Hill, NJ, USA |
Microfibrillar collagen | Avitene® | CR Bard Inc., Murray Hill, NJ, USA |
Chitosan | HemCon® | Tricol Biomedical Inc., Portland, OR, USA |
Chitoflex® | Tricol Biomedical Inc., Portland, OR, USA | |
TraumaStat® | Ore-Medix, LLC Company, Lebanon, OR, USA | |
Celox® | Medtrade Products LLC., Crewe, UK | |
ChitoSAM® | Sam Medical, Tualatin, OR, USA | |
Axiostat® | Axio Biosolutions PVT LTD. Gujarat, India | |
Biologically active topical hemostatic agents | ||
Topical thrombin | Thrombin JMI® | Pfizer Inc., New York, NY, USA |
Tranexamic acid (TXA) | Multiple generics | |
Cyklokapron® 100 mg/ml | Pfizer Inc., New York, NY, USA | |
Erfa Tranexamic® 100 mg/ml | Erfa Canada 2012, Inc., Montreal, QC, Canada | |
Kaolin | QuickClot® | Z-Medica LLC., Wallingford, CT, USA |
Topical hemostatic agents.
Little data exists to suggest superiority of a single agent over others, and often selection of an agent is based on availability, familiarity with its use, patient and wound characteristics, and cost.
Gelfoam® and Surgifoam® are porcine derived, non-soluble, gelatin matrices that are in a compressed sponge form [10, 11]. They can be cut to appropriate size for application and when applied to bleeding sites are able to absorb 45 times their weight in whole blood. Floseal® is a combination of bovine-derived, liquid gelatin matrix and human-derived thrombin that is supplied in a syringe with an applicator tip that assists with mixing the components and application at the site of bleeding [12]. The mechanism of action of gelatin matrix is poorly understood but is thought to be due to its physical properties, providing a structural support for clot formation rather than a direct effect on the clotting cascade. In clinical use, these agents are appropriate for topical application to persistently bleeding sites, such as dental extraction sites, in the management of epistaxis, and in fingertip avulsion injuries. These agents typically have minimal tissue reaction and are absorbed within 6 weeks when placed within soft tissues or liquified and absorbed within 2–5 days when applied to bleeding mucosal sites.
Little data exists studying the efficacy of gelatin matrices for bleeding complications in the emergency department setting. In a small prospective, randomized study of patients who failed anterior packing for epistaxis, Floseal® application demonstrated equal rates of hemostatic control as repeat anterior packing by a specialist, and lower, but not statistically significant, rates of hospitalization [13]. A larger, prospective randomized sample of patients with epistaxis managed initially with Floseal® versus anterior packing demonstrated that Floseal® was associated with improved patient satisfaction and less rebleeding [14]. In a small convenience sample of patients presenting with posterior epistaxis, Floseal® was successfully used to control bleeding in 80% of patients at a significantly reduced cost when compared to surgery, posterior packing with hospital admission, and embolization [15].
Complications from gelatin matrix applications are reported to be minimal but include the potential to form a nidus for infection or abscess formation, foreign body reactions with encapsulation of reactive fluid, and toxic shock when used in nasal application.
Surgicel® is a sterile, knitted, absorbable fabric produced from plant cellulose. The mechanism of action of Surgicel® is poorly understood, but is thought to produce a mechanical scaffolding for clot formation rather than have a direct effect on the clotting cascade [16]. In clinical use, these agents are appropriate for topical application to persistently bleeding sites, such as dental extraction sites and in the management of epistaxis. As opposed to the gelatin matrices, which can be used wet or dried, the efficacy of Surgicel® is superior if it is applied dry to the area of bleeding, so it may not be appropriate for use with topical thrombin. As Surgicel® undergoes reaction with the tissue, it produces an acidic environment, which has been demonstrated to have in vivo bactericidal properties. The acidic environment that it produces may impair wound healing, perhaps making it a less optimal choice for controlling bleeding in large areas of tissue avulsion. Complications of its use have primarily reported to be localized tissue reactions.
Arista® AH is a powder hemostatic agent derived from plant polysaccharides. The mechanism of action of Arista® is poorly understood, but is thought to produce a mechanical scaffolding for clot formation rather than have a direct effect on the clotting cascade [17]. Its powdered form has limited use in an emergency department environment.
Avitene® is a microfibrillar collagen hemostat available as a sponge, sheet, and powder. The collagen matrix of Avitene® is thought to promote platelet activation, inducing clot formation [18]. Avitene® has been on the market for more than 40 years and has widespread applications in surgical hemostasis and epistaxis treatment.
Chitosan is a naturally occurring polycationic polysaccharide derived from multiple sources including shrimp, crabs, and certain fungi. The hemostatic mechanism of chitosan is incompletely understood, but is thought to include gelatinous aggregation of red blood cells, platelet activation, and contact system activation [19].
In a case series of 35 patients on antiplatelet agents or anticoagulants who failed initial management with cautery and nasal packing, 32 patients were successfully treated with application of a foam anterior pack wrapped in a chitosan sheet [20]. A small study of 40 patients on oral anticoagulation undergoing multiple tooth extractions compared a site treated with a chitosan pledget with a site treated with gauze and pressure and found decreased bleeding times and decreased postoperative pain in the chitosan treated site [21]. Another small study of 20 patients on oral anticoagulants undergoing dental extraction of multiple teeth found that the extraction sites treated with chitosan had shorter bleeding times than control extraction sites treated with a collagen matrix plug [22].
Thrombin is a protein which is part of the clotting cascade and has the effect of activating fibrinogen to fibrin, which is essential for clot formation, as well as activating platelets. Several formulations exist on the market, and thrombin can be of bovine or human origin. Topical thrombin can be applied to mucosal bleeding sites such as dental sites and epistaxis or can be applied topically. Additionally, topical thrombin can be used in conjunction with gelatin matrix sponges. No clinical trials comparing efficacy to other techniques have been published. Because these products are derived from other species or individuals, the primary complications include sensitivity reactions or rarely antibody formation against factor V, resulting in life-threatening bleeding complications [23].
Tranexamic acid is a synthetic derivative of the amino acid lysine that inhibits fibrinolysis by reversibly blocking the interaction of plasminogen with the lysine fragments on fibrin. The intravenous formulation of TXA is typically 100 mg/ml, which is equivalent to a 10% solution. Intravenous TXA formulations can be used topically as adjuvant treatment for patients with epistaxis, oral bleeding, or bleeding from topical sites.
A randomized controlled trial of 216 patients who were randomized to receive an anterior nasal packing soaked in 5 ml of 10% solution versus lidocaine plus epinephrine found that those treated with TXA had more rapid resolution of bleeding and earlier emergency department discharge [24]. A study of 124 patients taking antiplatelet agents who were randomized to TXA versus anterior packing also found more rapid resolution of bleeding as well as decreased visits for rebleeding [25]. A retrospective analysis of oral bleeding in 542 patients demonstrated improvement in bleeding in patients treated with TXA-soaked gauze and compression over use of gauze alone [26]. A systematic review of 5 studies including 252 patients taking oral anticoagulants undergoing dental procedures found that TXA was significantly protective against bleeding with a RR of 0.13 (95% CI 0.05–0.36; p < 0.0001) [27]. In addition to using the intravenous formulation of TXA topically, a paste of TXA can be made by crushing several 650 mg TXA tablets and adding small aliquots of saline to form the paste.
Kaolin is an inorganic mineral that has been demonstrated to promote activation of Factor XII, which is the first step in the activation of the intrinsic pathway of the clotting cascade. Kaolin-impregnated gauze is primary developed for controlling hemorrhage from external wounds in non-compressible sites in the setting of military and civilian trauma.
Little data exists evaluating the effectiveness of kaolin gauze in humans. In swine models of uncontrolled hemorrhage, QuickClot® outperformed comparative hemostatic agents in terms of survival [28].
Although the manufacturer states that there are no complications with the use of QuickClot® because it is not biologically derived, there is a case report of thermal burn with its use [29].
When it comes to primary wound closure, skin adhesives have several advantages over traditional suture repair. They bond quickly, resulting in saved time on the part of the physician performing the repair, and they are less painful than standard suture repair [30, 31]. They do not require a second visit for suture removal, saving the patient time and reducing the burden to the health-care system [30]. The closure is strong, similar in strength to healed tissue at 7 days post-repair [30]. In addition, the closure with tissue adhesives is cosmetically similar to that achieved with standard suture closure [31]. Tissue adhesives are more expensive than suture materials, but that cost is offset by the inherent costs associated with physician time to suture, bandaging, and repeat visit for suture removal [32]. In a busy and unpredictable emergency department, this time saving is essential.
Unlike topical hemostatic agents, which are often natural polymers, tissue adhesives used for wound closure in the emergency department are primarily synthetic polymers [33]. This is largely due to their high tensile strength, flexibility, and ability to form mechanical bonds [33]. The three primary classes of tissue adhesives used for wound closure are polyurethane-based tissue adhesives, polyethylene glycol-based tissue adhesives, and cyanoacrylate synthetic glues [33].
Polyurethane-based tissue adhesives are not commonly used in emergency practice, although they do have applications in surgical practice. The isocyanate pre-polymers in the adhesive bond to the amines in tissue proteins, forming a urea bond [3]. Historically, there have been issues with polyurethane-based tissue adhesive toxicity (including thrombosis and hemolysis) and long setup time [3], but they are undergoing development currently using various concentrations of castor oil and other additives to optimize their surgical adhesive properties [34, 35]. Although there is currently some application of these adhesives in the operating theater in renal, plastics, and orthopedic surgery, they are not currently used for traumatic injuries typically seen in the emergency department. As they have shown promise in reducing seroma formation in surgical wounds, they may have applications for larger traumatic wounds in the future.
Polyethylene-based adhesives are not currently typically used in emergency practice. Like polyurethane-based adhesives, they are primarily used inside the body, with current uses most commonly related to sealing lung surgical sites and preventing dural leaks after neurosurgery [36]. These adhesives have a very fast setup time and are strong and biodegradable [36]. They have potential for emergency department application in the future.
Cyanoacrylate synthetic glues are by far the most common tissue adhesives used for wound repair in emergency departments (Table 2). These glues were initially developed during attempts to make a clear plastic. Initially, they were too brittle and caused significant inflammation to tissue but subsequently underwent tremendous redesign over the course of decades prior to their final approval by the FDA in the form of 2-octyl cyanoacrylate in the late 1990s [3, 30]. Cyanoacrylate glues are monomers that react upon contact with water on tissue in an exothermic reaction, causing them to polymerize across the wound edges, allowing healing to take place below. These agents are also antimicrobial, which is an additional advantage [3, 30, 32].
Product | Manufacturer | |
---|---|---|
Cyanoacrylate synthetic glues | Dermabond® | Ethicon Inc., Somerville, NJ, USA |
Histoacryl® | BBraun, Melsungen, Germany | |
SurgiSeal® | Adhezion Biomedical LLC., Reading, PA, USA | |
Periacryl® | GluStitch, Delta, BC, Canada | |
Glu-Stitch® | GluStitch, Delta, BC, Canada | |
Indermil® | Surgical Specialties, Frenchs Forest, NSW, Australia |
Tissue adhesives.
Cyanoacrylate glues have the tensile strength of 5-0 suture, and they reach their maximal bonding strength 2.5 min after application [30]. Given these properties, it stands to reason that wounds most appropriate for glue repair are wounds that would require a suture strength of 5-0 or 6-0. Therefore, cyanoacrylate synthetic glues are not recommended for wounds under tension such as those crossing joint lines, highly gaping wounds, or wounds in very moist areas of the body [30, 32]. It is acceptable to use tissue adhesive glue on wounds that require deep sutures to reduce tension and gaping on the wound, so long as after those sutures are placed, the wound would be appropriate for closure with 5-0 or 6-0 suture. Cosmetically, cyanoacrylate has similar outcomes to standard sutures in appropriately chosen lacerations but a slightly higher risk of dehiscence [30, 31].
Tissue adhesive should be applied to an appropriately cleaned and dry wound. The wound edges should be approximated, and the adhesive should be applied over the approximated edges three to four times [30]. The hydroxyl ions in the wound edges activate the adhesive and seal the wound. The adhesive should never be introduced into the wound. In addition to causing an exothermic reaction because of the amount of moisture, it creates a foreign body reaction, with tissue inflammation and poor healing [30, 32]. Tissue adhesives should therefore not be used on heavily contaminated wounds, bites, macerated wounds, or wounds that are complex and difficult to approximate [30, 31, 32].
Cyanoacrylate glues are used in oral surgery practice, but their use for dental injuries in the emergency department is currently off-label. Nevertheless, tissue adhesives have found a niche in emergency department management of dental injuries. In the setting of an acutely fractured tooth involving exposed dentin (which is extremely painful), standard of care is to cover the exposed fracture site with calcium hydroxide paste. If this is unavailable, some providers advocate for using cyanoacrylate glue to cover the exposed dentin, as it controls pain and can be removed without difficulty using a solvent in the dentist’s office [37, 38]. One study also evaluated the use of cyanoacrylate for pain control in carious teeth, which found it effective for pain control [38]. Cyanoacrylate has antimicrobial properties, which provides theoretical benefits in these settings. However, cyanoacrylate has not been studied for safety in these scenarios, nor has it been assessed for adverse events, only for pain control. Therefore, the physician needs to be aware that any use of cyanoacrylate in treatment of dental fractures in the emergency department setting is not evidence-based.
In patients with avulsed and replanted teeth or in those with subluxed teeth, cyanoacrylate can be useful in splinting the injured tooth.
Topical hemostatic agents, tissue adhesives, and sealants may have adverse effects usually related to the composition of the agent, location of placement of the agent, and the absorption times of the agent. Slowly degrading products can serve as a nidus for infection especially if excessive amounts are used. In many cases, these agents are used in confined places and can then lead to compression of surrounding structures. Many of the complications associated with these agents are related to surgical uses rather than emergency department applications [39].
Air embolism is a rare complication that has been reported with the use of injectable agents such as spray thrombin or fibrin sealant. Care must be taken when spraying these objects so as not to exceed recommended pressures and to spray at an appropriate distance from the affected tissue. There are no reported cases of air embolism secondary to use of an atomizer, as may be used with TXA [40, 41, 42].
Wound infection may be associated with the use of topical hemostatic agents. It is difficult to analyze the risk of infection due solely to hemostatic agents versus due to confounding factors. Adverse factors, such as type and location of wound, foreign body material in the wound, and etiology of the wound, all play a role in development of wound infection. If a patient has other systemic symptoms that need to be addressed and needs urgent or emergent wound closure, that too can play a role in development of wound infection. The risk of infection, as it relates to hemostatic agents, can be minimized by cleaning the wound thoroughly and removing excess topical agent after hemostasis is achieved.
Impaired wound healing may be due to failure to effectively close the wound, dehiscence of the wound repair, and excessive amounts of hemostatic agent being used. When excessive amount of agent is used, as in cyanoacrylate closure, increased metabolites can form and cause an inflammatory response in the surrounding tissue which leads to poor wound healing [43].
Hypotension has been reported in some individuals receiving injections of bovine-derived products, such as thrombin. The hypotension is believed to occur with higher than normal concentrations of bovine thrombin but has been noted to be mostly transient lasting less than a minute. The hypotension does respond to epinephrine, if needed, and can be avoided by reducing the amount of bovine thrombin used and compression of injection sites [44, 45, 46].
Anaphylaxis and allergic reactions are also mostly related to bovine-derived products. These products must be avoided in individuals with a history of prior anaphylactic reactions to plasma products or IgA deficiency [47].
Infectious disease transmission is a potential complication when any products using blood components are used, and transmission may be more likely when hemostatic agents are used in an aerosolized form. Though there is a theoretical risk of viral transmission, including HIV and hepatitis, with topical hemostatic agents, there have been no reported cases in the last 20 years [48].
Vascular thrombosis is also a theoretical risk; however, there is no increased rate of vascular or graft thrombosis with the use of topical hemostatic agents. Great care must be taken not to inject these agents into a blood vessel or opened vessel [49, 50].
An immune-mediated bleeding diathesis can occur with the use of bovine thrombin preparations. The diathesis occurs due to development of a factor V deficiency secondary to an antibovine factor V antibody that cross-reacts with endogenous factor V. The risk of this complication can be reduced by using human thrombin. If patients have prior exposure to a bovine thrombin, antibodies may persist for years, and if known bovine thrombin should be avoided [51, 52].
Much of the literature found on uses of topical hemostatic agents for bleeding involves surgical and perioperative indications. However, different bleeding scenarios may present to the emergency department where topical adhesives and hemostatic agents may be of benefit. We will discuss some of these indications, including cutaneous bleeding, varicosity bleeding, AV fistula bleeding, post-tooth extraction bleeding, and epistaxis.
Approximately 6 million minor wounds are treated in emergency departments in the United States every year. Most cutaneous bleeding occurs due to lacerations of the skin. These lacerations can be caused by blunt or penetrating trauma to the epidermal and dermal layers. Management of these minor wounds has three goals: control of bleeding, avoidance of infection, and cosmetically acceptable, functional scars. Many factors contribute to management of these wounds. The wound must be assessed, and factors such as age of injury, mechanism of injury, extent of wound, neurovascular injury, and location of wound all play a role in determining the type of closure employed. Hemostasis of these wounds must be accomplished, and most times simple pressure for 10–15 min can achieve this. Persistent bleeding may require lidocaine with epinephrine injected or applied to the wound. In those cases where bleeding is difficult to stop, the direct application of surgical absorbable gelatin foam (Gelfoam®) to the wound is an alternative method of achieving hemostasis. Gelfoam®, however, should not be used in infected wounds or at the skin closure site because it may delay healing. After achieving hemostasis, wounds may require debridement, irrigation, and foreign body removal. Once the wound has been adequately assessed and prepared, primary closure with suture, staples, skin tape, or topical adhesive may be utilized. The most common topical adhesives used in the emergency department are cyanoacrylate synthetic glues. These offer tensile strength equivalent to 5-0 sutures. They have similar cosmetic outcomes to sutures but do have a slightly higher risk of dehiscence [53, 54, 55].
Varicose veins are dilated, elongated, tortuous, subcutaneous veins 3 mm or greater in diameter. They may involve the saphenous veins, saphenous tributaries, or superficial leg veins. Complications of varicose veins most commonly include superficial vein thrombosis and bleeding and, though uncommon, may require immediate attention. Varicose veins located near bony prominences are more prone to hemorrhage, and bleeding is usually due to minor trauma. Hemorrhage, in most cases, can be controlled with direct pressure and elevation of the leg. When these measures fail to sufficiently control bleeding, injections with lidocaine with epinephrine, suturing, and topical hemostatic agents may be helpful. Though no formal studies have specifically looked at topical agents to help with varicose bleeding, anecdotally, the use of topical thrombin, TXA, and absorbable gelatin foam may stop bleeding or control it until more definitive surgical interventions can be performed [56, 57].
Arteriovenous (AV) fistula is the vascular access preferred for long-term hemodialysis in patients with end-stage renal disease. Hemodialysis accesses are subject to complications such as clotting, stenosis, infection, and hemorrhage. Access complications are common among hemodialysis patients, but they are usually not life-threatening. Fatal vascular access hemorrhage is very rare with an incidence of only 0.4%, but when these patients present to the emergency department, various measures can be employed in order to control the bleeding until definitive measures can be taken, usually by a vascular surgeon. Most of the literature regarding fistula bleeding is related to intraoperative bleeding which can be controlled with suturing, topical thrombin, and cellulose gelatin foam. Extrapolating this data, one could conclude that emergency department management of AV fistula bleeding should involve direct pressure to the site of bleeding with the aid of topical thrombin products and gelatin foam products. Definitive treatment usually will involve suture repair done by a vascular surgeon either in the emergency department or operating room [58].
Post-extraction bleeding is a recognized, frequently encountered complication in dental practices. It is defined as bleeding that continues beyond 8–12 hours after dental extraction. The incidence of post-extraction bleeding varies from 0 to 26%. If post-extraction bleeding is not managed, complications can range from soft tissue hematomas to severe blood loss. Local causes of bleeding include soft tissue and bone bleeding. Systemic causes include platelet problems, coagulation disorders, or excessive fibrinolysis. There is a wide array of techniques suggested for the treatment of post-extraction bleeding, which include interventions aimed at both local and systemic causes. Many of these patients will present to the emergency department with their bleeding complications. In addition to treating systemic causes, many techniques can be employed to control the local etiologies of the bleeding. Surgical interventions mainly involve suturing of the site. In addition, nonsurgical hemostatic measures can be employed as well as combination therapy with surgical and nonsurgical techniques. Nonsurgical measures commonly include hemostatic agents such as oxidized cellulose, gel foam, thrombin, collagen fleeces, cyanoacrylate glue, acrylic or surgical splints, and local antifibrinolytic solutions, such as tranexamic acid mouthwash [59].
Epistaxis is a common problem encountered in the emergency department. It occurs in up to 60% of the general population; however, 10% or fewer seek medical attention. Epistaxis can be classified as anterior with the common source of bleeding being Kiesselbach’s plexus or posterior with the source being the sphenopalatine artery. Initial treatment at home or in the emergency department include conservative measures such as blowing the nose to remove clots, using vasoconstrictive sprays such as oxymetazoline, applying steady pressure for 10 minutes, placing cold compresses on the bridge of the nose, placing a cotton pledget in the nostril, and having the patient bend forward so as not to accumulate blood in the oropharynx. When these measures fail, more invasive measures can be used such as cautery, nasal packing with tampons, gauze, or balloon catheters. There has recently been more literature regarding the use of thrombogenic foams and gels as well as the use of TXA as an adjunct to these measures. Fibrin glue is a safe and effective addition and has been shown to be as effective as cautery and packing [60]. Thrombin gel, such as Floseal, was associated with an absolute 26% lower rebleeding rate compared with nasal packing and was easier to insert and judged more satisfactory by both providers and patients in a randomized trial of 70 patients with acute anterior nosebleeds [14]. In another prospective study, FloSeal® effectively controlled posterior bleeds in 8 of 10 patients whose initial packing failed [61]. Surgicel® and Gelfoam® are common conformable hemostatic materials and have been described in reviews or small case series as useful in nasal bleeding refractory to cautery [62]. These materials can be trimmed to an appropriate size and then applied directly to the bleeding source. Tranexamic acid has been studied for epistaxis and has shown some benefit in both short-term cessation of bleeding and decreasing rates of rebleeding. There was also a trend towards improved control of bleeding when directly compared to nasal packing alone. The delivery of TXA can be done by using an atomizer and/or saturating nasal tampons with topical application of 500 mg of the IV formulation (TXA 100 mg/ml). Care must be taken in patients with higher risk of systemic thrombosis as systemic absorption may be variable when TXA is applied to the nasal mucosa [63].
A number of products are available to assist in topical hemostasis. The choice of which product to use is based partly on availability as well as the particular application. Similarly, there are multiple tissue adhesives available on the market, but the provider will likely be limited to one or two different products.
The authors declare no conflicts of interest to disclose.
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