Preoperative resuscitation of the trauma patient

Comparison of hydroxocobalamin with other resuscitative fluids in volume-controlled and uncontrolled hemorrhage models in swine ( Sus-scrofa )

BACKGROUND

Traumatic hemorrhage is the leading cause of preventable death in military environments. Treatment with resuscitative fluids and blood components is based on availability, thus, frequently unavailable in the prehospital setting, due to lack of resources and costs. Hydroxocobalamin (HOC), increases blood pressure via nitric oxide scavenging. We evaluated HOC as a resuscitation fluid, in two swine hemorrhage models. Our objectives were to (1) evaluate whether HOC treatment following hemorrhagic shock improves hemodynamic parameters and (2) determine whether those effects are comparable to whole blood (WB) and lactated ringers (LR).

METHODS

Yorkshire swine (S us scrofa ) (n = 72) were used in models of controlled hemorrhage (CH) (n = 36) and uncontrolled hemorrhage (UH) (n = 36). Randomized animals received treatment with 500 mL of either WB, LR, HOC (150 mg/kg), followed by a six-hour observation (n = 6 each group). Survival, hemodynamics, blood gases (ABGs) and chemistries were collected. Data reported as mean ± standard error of the mean and statistical analysis by ANOVA ( p < 0.05).

RESULTS

Blood loss for CH was 41% ± 0.02 versus 33% ± 0.07 for UH. For CH, HOC treatment maintained higher systolic blood pressure (sBP, mm Hg) compared with WB and LR (72 ± 1.1; 60 ± 0.8; 58 ± 1.6; respectively). Heart rate (HR), cardiac output (CO), Sp o2 and vascular resistance were comparable with WB and LR. The ABG values were comparable between HOC and WB. For UH, HOC treatment maintained sBP levels comparable to WB and higher than LR (70 ± 0.9; 73 ± 0.5; 56 ± 1.2). HR, CO, Sp o2 , and systemic vascular resistance were comparable between HOC and WB. Survival, hemodynamics, blood gases were comparable between HOC and WB. No survival differences were found between cohorts.

CONCLUSION

Hydroxocobalamin treatment improved hemodynamic parameters and Ca 2+ levels compared with LR and equivalent to WB, in both models. Hydroxocobalamin may be a viable alternative when WB is not available.

Timing of major fracture care in polytrauma patients - An update on principles, parameters and strategies for 2020

OBJECTIVES

Sustained changes in resuscitation and transfusion management have been observed since the turn of the millennium, along with an ongoing discussion of surgical management strategies. The aims of this study are threefold: a) to evaluate the objective changes in resuscitation and mass transfusion protocols undertaken in major level I trauma centers; b) to summarize the improvements in diagnostic options for early risk profiling in multiply injured patients and c) to assess the improvements in surgical treatment for acute major fractures in the multiply injured patient.

METHODS

I. A systematic review of the literature (comprehensive search of the MEDLINE, Embase, PubMed, and Cochrane Central Register of Controlled Trials databases) and a concomitant data base (from a single Level I center) analysis were performed. Two authors independently extracted data using a pre-designed form. A pooled analysis was performed to determine the changes in the management of polytraumatized patients after the change of the millennium. II. A data base from a level I trauma center was utilized to test any effects of treatment changes on outcome.

INCLUSION CRITERIA

adult patients, ISS > 16, admission < less than 24 h post trauma. Exclusion: Oncological diseases, genetic disorders that affect the musculoskeletal system. Parameters evaluated were mortality, ICU stay, ICU complications (Sepsis, Pneumonia, Multiple organ failure).

RESULTS

I. From the electronic databases, 5141 articles were deemed to be relevant. 169 articles met the inclusion criteria and a manual review of reference lists of key articles identified an additional 22 articles. II. Out of 3668 patients, 2694 (73.4%) were male, the mean ISS was 28.2 (SD 15.1), mean NISS was 37.2 points (SD 17.4 points) and the average length of stay was 17.0 days (SD 18.7 days) with a mean length of ICU stay of 8.2 days (SD 10.5 days), and a mean ventilation time of 5.1 days (SD 8.1 days). Both surgical management and nonsurgical strategies have changed over time. Damage control resuscitation, dynamic analyses of coagulopathy and lactate clearance proved to sharpen the view of the worsening trauma patient and facilitated the prevention of further complications. The subsequent surgical care has become safer and more balanced, avoiding overzealous initial surgeries, while performing early fixation, when patients are physiologically stable or rapidly improving. Severe chest trauma and soft tissue injuries require further evaluation.

CONCLUSIONS

Multiple changes in management (resuscitation, transfusion protocols and balanced surgical care) have taken place. Moreover, improvement in mortality rates and complications associated with several factors were also observed. These findings support the view that the management of polytrauma patients has been substantially improved over the past 3 decades.

Preoperative fluid restriction for trauma patients with hemorrhagic shock decreases ventilator days

Aim

In recent years, with the concept of damage control resuscitation, hemostasis and preoperative fluid restriction have been carried out, but there is controversy regarding the effectiveness of fluid restriction.

Methods

From April 2007 to March 2013, 101 trauma patients presented with hemorrhagic shock (systolic blood pressure ≤90 mmHg) at the prehospital or emergency department and were admitted to Hyogo Emergency Medical Center (Hyogo, Japan). They underwent emergency hemostasis by surgery and transcatheter arterial embolization. We compared two groups in a historical cohort study, the aggressive fluid resuscitation (AR) group, which included 59 cases treated in the period April 2007-March 2010, and the fluid restriction (FR) group, which included 42 cases treated in the period April 2010-March 2013.

Results

There was no difference between both groups in patient background (heart rate, 110 b.p.m.; systolic blood pressure, 70 mmHg). The Injury Severity Score was 34 (AR) versus 38 (FR) (not significant). Preoperative infusion volume of crystalloid significantly decreased, from 2310 mL (AR) to 1025 mL (FR) (P ≤ 0.01). There was no difference in mortality (36% [AR] versus 41% [FR]). Ventilator days significantly decreased, from 8.5 days (AR) to 5.5 days (FR) (P = 0.02).

Conclusions

Preoperative fluid restriction for trauma patients with hemorrhagic shock did not improve mortality, but it decreased ventilator days by reducing the perioperative plus water balance and it might contribute to perioperative intensive care.

Evaluation of the clinical effect of small-volume resuscitation on uncontrolled hemorrhagic shock in emergency

OBJECTIVE

The objective of the present study was to explore the resuscitative effect of small-volume resuscitation on uncontrolled hemorrhagic shock in emergency.

METHODS

In this study, the resuscitative effects in 200 trauma patients with uncontrolled hemorrhagic shock in emergency were studied. Half of these patients were infused with hypertonic/hyperoncotic fluid (small-volume resuscitation group, n=100), whereas the rest were infused with Hespan and lactated Ringer's solution (conventional fluid resuscitation group, n=100). The changes in hemodynamics, coagulation function, blood biochemistry, blood hematology, and the average infusion volume in both the groups were comparatively studied.

RESULTS

It was found that the hemodynamics were improved in both the groups after resuscitation. Interestingly, compared with trauma patients infused with Hespan and lactated Ringer's solution, the growth rate, range, and time duration of the mean arterial pressure of the patients in small-volume resuscitation group increased significantly, and the shock index decreased progressively; in the 60th min after the resuscitation, blood index including hemoglobin, hematocrit, red blood cells, white blood cells, and platelet declined, whereas prothrombin time and activated partial thromboplastin time were prolonged in both the groups, but these changes were less obvious in the small-volume group. In addition, the average infusion volume of patients in the small-volume group was less than that of patients in conventional fluid resuscitation group.

CONCLUSION

Featured with small infusion volume and less influence to coagulation function and homeostasis of human body, small-volume resuscitation possesses a significantly higher resuscitative effect. Therefore, trauma patients may have a better chance to maintain the hemodynamic stability and the survival rate, or recovery speed will be increased when traditional aggressive fluid resuscitation is replaced by small-volume resuscitation.

Permissive hypotension/hypotensive resuscitation and restricted/controlled resuscitation in patients with severe trauma

Achieving a balance between organ perfusion and hemostasis is critical for optimal fluid resuscitation in patients with severe trauma. The concept of “permissive hypotension” refers to managing trauma patients by restricting the amount of resuscitation fluid and maintaining blood pressure in the lower than normal range if there is continuing bleeding during the acute period of injury. This treatment approach may avoid the adverse effects of early, high-dose fluid resuscitation, such as dilutional coagulopathy and acceleration of hemorrhage, but does carry the potential risk of tissue hypoperfusion. Current clinical guidelines recommend the use of permissive hypotension and controlled resuscitation. However, it is not mentioned which subjects would receive most benefit from this approach, when considering factors such as age, injury mechanism, setting, or the presence or absence of hypotension. Recently, two randomized clinical trials examined the efficacy of titrating blood pressure in younger patients with shock secondary to either penetrating or blunt injury; in both trials, overall mortality was not improved. Another two major clinical trials suggest that controlled resuscitation may be safe in patients with blunt injury in the pre-hospital setting and possibly lead to improved outcomes, especially in patients with pre-hospital hypotension. Some animal studies suggest that hypotensive resuscitation may improve outcomes in subjects with penetrating injury where bleeding occurs from only one site. On the other hand, hypotensive resuscitation in blunt trauma may worsen outcomes due to tissue hypoperfusion. The influence of these approaches on coagulation has not been sufficiently examined, even in animal studies. The effectiveness of permissive hypotension/hypotensive resuscitation and restricted/controlled resuscitation is still inconclusive, even when examining systematic reviews and meta-analyses. Further investigation is needed to elucidate the effectiveness of these approaches, so as to develop improved treatment strategies which take into account coagulopathy in the pathophysiology of trauma.

A prospective, randomized trial of intravenous hydroxocobalamin versus whole blood transfusion compared to no treatment for Class III hemorrhagic shock resuscitation in a prehospital swine model

OBJECTIVES

The objective was to compare systolic blood pressure (sBP) over time in swine that have had 30% of their blood volume removed (Class III shock) and treated with intravenous (IV) whole blood or IV hydroxocobalamin, compared to nontreated control animals.

METHODS

Thirty swine (45 to 55 kg) were anesthetized, intubated, and instrumented with continuous femoral and pulmonary artery pressure monitoring. Animals were hemorrhaged a total of 20 mL/kg over a 20-minute period. Five minutes after hemorrhage, animals were randomly assigned to receive 150 mg/kg IV hydroxocobalamin solubilized in 180 mL of saline, 500 mL of whole blood, or no treatment. Animals were monitored for 60 minutes thereafter. A sample size of 10 animals per group was determined based on a power of 80% and an alpha of 0.05 to detect an effect size of at least a 0.25 difference (>1 standard deviation) in mean sBP between groups. sBP values were analyzed using repeated-measures analysis of variance (RANOVA). Secondary outcome data were analyzed using repeated-measures multivariate analysis of variance (RMANOVA).

RESULTS

There were no significant differences between hemodynamic parameters of IV hydroxocobalamin versus whole blood versus control group at baseline (MANOVA; Wilks' lambda; p = 0.868) or immediately posthemorrhage (mean sBP = 47 mm Hg vs. 41 mm Hg vs. 37 mm Hg; mean arterial pressure = 39 mm Hg vs. 28 mm Hg vs. 34 mm Hg; mean serum lactate = 1.2 mmol/L vs. 1.4 mmol/L vs. 1.4 mmol/L; MANOVA; Wilks' lambda; p = 0.348). The outcome RANOVA model detected a significant difference by time between groups (p < 0.001). Specifically, 10 minutes after treatment, treated animals showed a significant increase in mean sBP compared to nontreated animals (mean sBP = 76.3 mm Hg vs. 85.7 mm Hg vs. 51.1 mm Hg; p < 0.001). RMANOVA modeling of the secondary data detected a significant difference in mean arterial pressure, heart rate, and serum lactate (p < 0.001). Similar to sBP, 10 minutes after treatment, treated animals showed a significant increase in mean arterial pressure compared to nontreated animals (mean arterial pressure = 67.7 mm Hg vs. 61.4 mm Hg vs. 40.5 mm Hg). By 10 minutes, mean heart rate was significantly slower in treated animals compared to nontreated animals (mean heart rate = 97.3 beats/min vs. 95.2 beats/min vs. 129.5 beats/min; p < 0.05). Serum lactate, an early predictor of shock, continued to rise in the control group, whereas it did not in treated animals. Thirty minutes after treatment, serum lactate values of treated animals were significantly lower compared to nontreated animals (p < 0.05). This trend continued throughout the 60-minute observation period such that 60-minute values for lactate were 1.4 mmol/L versus 1.1 mmol/L versus 3.8 mmol/L. IV hydroxocobalamin produced a statistically significant increase in systemic vascular resistance compared to control, but not whole blood, with a concomitant decrease in cardiac output.

CONCLUSIONS

Intravenous hydroxocobalamin was more effective than no treatment and as effective as whole blood transfusion, in reversing hypotension and inhibiting rises in serum lactate in this prehospital, controlled, Class III swine hemorrhage model.

Management of patients who refuse blood transfusion

A small group of people belonging to a certain religion, called Jehovah's witness do not accept blood transfusion or blood products, based on biblical readings. When such group of people are in need of health care, their faith and belief is an obstacle for their proper treatment, and poses legal, ethical and medical challenges for attending health care provider. Due to the rapid growth in the membership of this group worldwide, physicians attending hospitals should be prepared to manage such patients. Appropriate management of such patients entails understanding of ethical and legal issues involved, providing meticulous medical management, use of prohaemostatic agents, essential interventions and techniques to reduce blood loss and hence, reduce the risk of subsequent need for blood transfusion. An extensive literature search was performed using search engines such as Google scholar, PubMed, MEDLINE, science journals and textbooks using keywords like ‘Jehovah's witness’, ‘blood haemodilution’, ‘blood salvage’ and ‘blood substitutes’.

Liberal versus restricted fluid resuscitation strategies in trauma patients: a systematic review and meta-analysis of randomized controlled trials and observational studies*

OBJECTIVE

Hemorrhage is responsible for most deaths that occur during the first few hours after trauma. Animal models of trauma have shown that restricting fluid administration can reduce the risk of death; however, studies in patients are difficult to conduct due to logistical and ethical problems. To maximize the value of the existing evidence, we performed a meta-analysis to compare liberal versus restricted fluid resuscitation strategies in trauma patients.

DATA SOURCES

Medline and Embase were systemically searched from inception to February 2013.

STUDY SELECTION

We selected randomized controlled trials and observational studies that compared different fluid administration strategies in trauma patients. There were no restrictions for language, population, or publication year.

DATA EXTRACTION

Four randomized controlled trials and seven observational studies were identified from 1,106 references. One of the randomized controlled trials suffered from a high protocol violation rate and was excluded from the final analysis.

DATA SYNTHESIS

The quantitative synthesis indicated that liberal fluid resuscitation strategies might be associated with higher mortality than restricted fluid strategies, both in randomized controlled trials (risk ratio, 1.25; 95% CI, 1.01-1.55; three trials; I(2), 0) and observational studies (odds ratio, 1.14; 95% CI, 1.01-1.28; seven studies; I(2), 21.4%). When only adjusted odds ratios were pooled for observational studies, odds for mortality with liberal fluid resuscitation strategies increased (odds ratio, 1.19; 95% CI, 1.02-1.38; six studies; I(2), 26.3%).

CONCLUSIONS

Current evidence indicates that initial liberal fluid resuscitation strategies may be associated with higher mortality in injured patients. However, available studies are subject to a high risk of selection bias and clinical heterogeneity. This result should be interpreted with great caution.

Preferences of critical care registrars in fluid resuscitation of major trauma patients: concordance with current guidelines

Fluid resuscitation of patients with major trauma remains a controversial topic. We hypothesised that current practice amongst critical care registrars at our centre might differ from current clinical guidelines. Sixty-six registrars from anaesthesia, intensive care and emergency medicine completed a survey giving their preferences for fluid resuscitation in major trauma patients. Most (85%) appropriately would choose a crystalloid (normal saline 68%, Hartmann's solution 17%), although intensive care registrars reported an early preference for colloids (20% of intensive care registrars would choose a colloid vs 0% of other departmental registrars, P < 0.01). Many responses indicated that the presence of an acidosis would not influence their choice of primary resuscitation fluid. Few participants were unfamiliar with the current practice of avoiding colloids as a primary resuscitation fluid in head-injured patients. Most (62%) would choose to transfuse trauma patients after 2 litres of crystalloid, although there was significant inter-departmental variation (P < 0.01). In addition, participants would transfuse an older patient (P=0.02) or an actively bleeding patient (P < 0.01) earlier than the younger or not visibly bleeding trauma patient. We concluded that our study demonstrated general consistency with current clinical guidelines but with interesting interdepartmental variations. We suggest that this type of study could enhance clinical practice by pointing to targeted additional learning opportunities.

Emergency medical services transport decisions in posttraumatic circulatory arrest: are national practices congruent?

OBJECTIVE

To catalog the 9-1-1 emergency medical services (EMS) transport practices for posttraumatic circulatory arrest patients (PTCAPs) in the majority of the nation's largest municipalities and to compare those practices to guidelines recommended by the National Association of EMS Physicians (NAEMSP) and American College of Surgeons Committee on Trauma (ACSCOT).

METHODS

A survey was conducted in 33 of the nation's largest cities primarily to determine whether or not individual EMS systems transport PTCAPs to hospitals and, if so, whether or not the initial electrocardiographic (ECG) rhythm or mechanism of injury affected those transport decisions.

RESULTS

All 33 cities (100%) responded. Seven (21%) indicated that EMS would transport an "asystolic blunt trauma patient" emergently or "leave the transport decision to paramedic judgment" despite NAEMSP-ACSCOT guidelines to terminate resuscitation in such cases. Likewise, 15 (46%) of the 33 EMS agencies would transport "asystolic penetrating trauma patients" emergently. Similarly, 27 (82%) would transport penetrating injury patients and 20 (61%) would transport blunt trauma patients with persistent ECG activity but no palpable pulses. However, only five systems had policies that included a minimum ECG heart rate criterion for transport, and all agencies that monitor ECG (n = 32) would transport PTCAPs found with ventricular fibrillation.

CONCLUSIONS

Many of the nation's highest volume EMS systems transport certain PTCAPs emergently, contrary to NAEMSP-ACSCOT guidelines to terminate resuscitative efforts in such cases. Reasons for these discrepancies should be evaluated to help better delineate applicable consensus guidelines for large urban EMS agencies.

Operational critical care. Intensive care and trauma

Trauma management involves good prehospital, emergency, surgical, anaesthetic and intensive care decision-making. Optimal outcome depends on keeping abreast of the latest thinking in an ever-changing and increasingly technology-rich environment. The intensive care unit needs to represented as early as possible in the damage-control resuscitation phase. Improved trauma system care has resulted in an increasing number of multiply injured military patients surviving their initial trauma. These patients require intensive care and are at risk from sepsis and multiple organ failure. Attention to detail is important, preservation of organ function, infection control and nutrition to maintain muscle strength allowing normal metabolic function to return. Multiply injured patients often require lengthy periods of mechanical ventilation and a variety of therapeutic interventions may have to be considered during management of the disease process. As we are now seeing more survivors in the military trauma system the focus now needs to be morbidity reduction in order for these survivors to be best prepared for their rehabilitation phase of care.

Initial resuscitation with plasma and other blood components reduced bleeding compared to hetastarch in anesthetized swine with uncontrolled splenic hemorrhage

BACKGROUND

Damage control resuscitation recommends use of more plasma and less crystalloid as initial resuscitation in treating hemorrhage. The purpose of this study was to evaluate resuscitation with either blood components or conventional fluids on coagulation and blood loss.

STUDY DESIGN AND METHODS

Isofluorane-anesthetized, instrumented pigs (eight per group) underwent controlled hemorrhage of 24 mL/kg, 20-minute shock period, splenic injury with 15-minute initial bleeding, and hypotensive fluid resuscitation. Lactated Ringer's (LR) was infused at 45 mL/kg while hetastarch (high-molecular-weight hydroxyethyl starch 6%, Hextend, Hospira, Inc., Lake Forest, IL) and blood component (fresh-frozen plasma [FFP], 1:1 FFP:[red blood cells] RBCs, 1:4 FFP : RBCs, and fresh whole blood [FWB]) were infused at 15 mL/kg. Postresuscitation blood loss (PRBL), hemodynamics, coagulation, hematocrit, and oxygen metabolism were measured postinjury for 5 hours.

RESULTS

Resuscitation with any blood component reduced PRBL of 52% to 70% compared to Hextend, with FFP resulting in the lowest PRBL. PRBL with LR (11.5 ± 3.0 mL/kg) was not significantly different from Hextend (17.9 ± 2.5 mL/kg) or blood components (range, 5.5 ± 1.5 to 8.6 ± 2.6 mL/kg). The volume expansion effect of LR was transient. All fluids produced similar changes in hemodynamics, oxygen delivery, and demand despite the oxygen-carrying capacity of RBC-containing fluids. Compared with other fluids, Hextend produced greater hemodilution and reduced coagulation measures, which could be caused by an indirect dilutional effect or a direct hypocoagulable effect.

CONCLUSIONS

These data suggest that blood products as initial resuscitation fluids reduced PRBL from a noncompressible injury compared to Hextend, preserved coagulation, and provided sustained volume expansion. There were no differences on PRBL among RBCs-to-FFP, FWB, or FFP in this nonmassive transfusion model.

Effects of fluid resuscitation with hypertonic saline dextrane or Ringer's acetate after nonhemorrhagic shock caused by pulmonary contusion

BACKGROUND

Injured lungs are sensitive to fluid resuscitation after trauma. Such treatment can increase lung water content and lead to desaturation. Hypertonic saline with dextran (HSD) has hyperosmotic properties that promote plasma volume expansion, thus potentially reducing these side effects. The aim of this study was to (1) evaluate whether fluid treatment counteracts hypotension and improves survival after nonhemorrhagic shock caused by lung contusion and (2) analyze whether resuscitation with HSD is more efficient than treatment with Ringer's acetate (RA) in terms of blood oxygenation, the amount of lung water, circulatory effects, and inflammatory response.

METHODS

Twenty-nine pigs, all wearing body armor, were shot with a 7.62-mm assault rifle to produce a standardized pulmonary contusion. These animals were allocated into three groups: HSD, RA, and an untreated shot control group. Exposed animals were compared with animals not treated with fluid and shot with blank ammunition. For 2 hours after the shot, the inflammatory response and physiologic parameters were monitored.

RESULTS

The impact induced pulmonary contusion, desaturation, hypotension, increased heart rate, and led to an inflammatory response. No change in blood pressure was observed after fluid treatment. HSD treatment resulted in significantly less lung water (p < 0.05) and tended to give better Pao2 (p = 0.09) than RA treatment. Tumor necrosis factor-α release and heart rate were significantly lower in animals given fluids.

CONCLUSION

Fluid treatment does not affect blood pressure or mortality in this model of nonhemorrhagic shock caused by lung contusion. However, our data indicate that HSD, when compared with RA, has advantages for the injured lung.

Advances in resuscitation strategies

Shock, regardless of etiology is characterized by decreased delivery of oxygen and nutrients to the tissues and our interventions are directed towards reversing the cellular ischemia and preventing its consequences. The treatment strategies that are most effective in achieving this goal obviously depend upon the different types of shock (hemorrhagic, septic, neurogenic and cardiogenic). This brief review focuses on the two leading etiologies of shock in the surgical patients: bleeding and sepsis, and addresses a number of new developments that have profoundly altered the treatment paradigms. The emphasis here is on new research that has dramatically altered our treatment strategies rather than the basic pathophysiology of shock.

Resuscitation center designation: recommendations for emergency medical services practices

Regionalization of medical resources by designating specialty receiving centers, such as trauma and stroke centers, within emergency medical services (EMS) systems is intended to ensure the highest-quality patient care in the most efficient and fiscally responsible fashion. Significant advances in the past decade such as induction of therapeutic hypothermia following resuscitation from cardiac arrest and a time-driven, algorithmic approach to management of septic patients have created compelling arguments for similar designation for specialized resuscitative interventions. Resuscitation of critically ill patients is both labor- and resource-intensive. It can significantly interrupt emergency department (ED) patient throughput. In addition, clinical progress in developing resuscitation techniques is often dependent on the presence of a strong research infrastructure to generate and validate new therapies. It is not feasible for many hospitals to make the commitment to care for large numbers of critically ill patients and the accompanying investigational activities, whether in the prehospital, ED, or inpatient arena. Because of this, the question of whether EMS systems should designate specific hospitals as "resuscitation centers" has now come center stage. Just as EMS systems currently delineate criteria and monitor compliance for trauma, ST-elevation myocardial infarction (STEMI), and stroke centers, strong logic now exists to develop similar standards for resuscitation facilities. Accordingly, this discussion reviews the current applicable trends in resuscitation science and presents a rationale for resuscitation center designation within EMS systems. Potential barriers to the establishment of such centers are discussed and strategies to overcome them are proposed.

Emerging therapies in traumatic hemorrhage control

PURPOSE OF REVIEW

Care of the injured patient is a dynamic process. Hemorrhage remains the primary cause of preventable death after trauma. Rapid and effective early care can improve survival and outcomes. Emerging therapies to address traumatic hemorrhage will be discussed.

RECENT FINDINGS

Current concepts in trauma care include damage control resuscitation with rapid surgical correction of bleeding; prevention of the development of the lethal triad; limitation of crystalloid administration and application of high ratios of plasma and platelets to packed red blood cells. Prehospital resuscitation strategies can effect care of the hemorrhaging trauma patient, as well. The goal should be to preserve vital functions without increasing the risk for further bleeding. The concept of hypotensive resuscitation has been formulated to address this issue. The type of resuscitation fluid also plays an important role, with novel fluids currently being studied for routine use. Compressible hemorrhage constitutes an important component of potentially survivable injury. Hemostatic dressings and tourniquets can prove essential to the management of combat and civilian wounds.

SUMMARY

Given the potential to preserve life with appropriate attention applied to the bleeding trauma victim, it is vitally important to explore the options currently available and continue to make improvements in care.

Airway management and initial resuscitation of the trauma patient

PURPOSE OF REVIEW

This review will analyze and comment on selected recent literature pertaining to airway management and initial fluid resuscitation in the trauma patient. It will also review airway devices currently being used in the trauma setting.

RECENT FINDINGS

Although a recent study has questioned the efficacy of manual inline immobilization, this technique continues to be endorsed by trauma guidelines and is safely used in most trauma centers. Clinicians have also incorporated the use of videolaryngoscopy and other adjuncts for difficult airway management in trauma patients. However, no single airway management tool has proven to be superior in this setting. Crystalloid solutions remain frontline therapy for the initial resuscitation of the hemorrhagic trauma patient, as studies with hypertonic saline and vasopressors have not shown superior results. Conversely, increased amounts of fresh frozen plasma and fibrinogen have been reported to increase survival in trauma patients.

SUMMARY

As trauma continues to be a major cause of morbidity and mortality worldwide, the use of newer airway adjuncts needs to be specifically investigated in trauma patients, as this population frequently has airway management difficulties. Further research is also required to elucidate the type and amount of fluid that will provide an adequate organ perfusion without increasing nonsurgical bleeding.