A momentary pause

R A Cowley, the “Golden Hour,” the “Momentary Pause,” and the “Third Space”

R Adams Cowley (1917–1991), the Baltimore thoracic and trauma surgeon, was an outstanding politician and promoter of emergency medical services. His skills included the effective use of language, for example, identifying the critical time immediately after injury as a “golden hour,” and describing shock as a “momentary pause in the act of death.” Conversely, Cowley avoided the tendency of some contemporaries to justify massive crystalloid infusion by invoking a “third space.” Cowley is often assumed to have originated the first two phrases, but, in fact, their histories go back at least to the 19th century and illustrate the development of surgical science. The “third space” is often assumed to have originated with Cowley's contemporary, Tom Shires (1925–2007), but, in fact, neither of them used the phrase to describe Shires’ controversial theories about an extracellular fluid deficit after trauma. Reviewing the actual etymology of these terms may help clarify the history of the underlying scientific ideas and enable more effective communication in the future.

Regional carbon dioxide monitoring: a different look at tissue perfusion

Adequate tissue oxygenation is one of the main therapeutic goals for the critically ill patient. Until recently, the perfusion status of the critically ill and injured has been assessed by global indices such as blood pressure, heart rate, and urine output. However, these global parameters are inadequate in that they fail to demonstrate the actual perfusion status of a patient. Research has shown the splanchnic region to be a pivotal organ bed in response to shock. Because this region shows early signs of hypoperfusion and hypoxia, its monitoring provides for more effective and complete resuscitation. To that end, gastric tonometry offers a noninvasive means by which early symptoms of low flow can be determined, allowing for optimization of tissue perfusion and patient outcome. The most proximal segment of the gastrointestinal tract offers promising information regarding tissue perfusion with the use of sublingual capnography.