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Arnold S, Watts S, Kirkman E, Page CP, Pitchford SC. Single and Multiplex Immunohistochemistry to Detect Platelets and Neutrophils in Rat and Porcine Tissues. Methods Protoc 2022; 5:mps5050071. [PMID: 36136817 PMCID: PMC9498441 DOI: 10.3390/mps5050071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 09/08/2022] [Accepted: 09/08/2022] [Indexed: 12/03/2022] Open
Abstract
Platelet–neutrophil complexes (PNCs) occur during the inflammatory response to trauma and infections, and their interactions enable cell activation that can lead to tissue destruction. The ability to identify the accumulation and tissue localisation of PNCs is necessary to further understand their role in the organs associated with blast-induced shock wave trauma. Relevant experimental lung injury models often utilise pigs and rats, species for which immunohistochemistry protocols to detect platelets and neutrophils have yet to be established. Therefore, monoplex and multiplex immunohistochemistry protocols were established to evaluate the application of 22 commercially available antibodies to detect platelet (nine rat and five pig) and/or neutrophil (four rat and six pig) antigens identified as having potential selectivity for porcine or rat tissue, using lung and liver sections taken from models of polytrauma, including blast lung injury. Of the antibodies evaluated, one antibody was able to detect rat neutrophil elastase (on frozen and formalin-fixed paraffin embedded (FFPE) sections), and one antibody was successful in detecting rat CD61 (frozen sections only); whilst one antibody was able to detect porcine MPO (frozen and FFPE sections) and antibodies, targeting CD42b or CD49b antigens, were able to detect porcine platelets (frozen and FFPE and frozen, respectively). Staining procedures for platelet and neutrophil antigens were also successful in detecting the presence of PNCs in both rat and porcine tissue. We have, therefore, established protocols to allow for the detection of PNCs in lung and liver sections from porcine and rat models of trauma, which we anticipate should be of value to others interested in investigating these cell types in these species.
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Affiliation(s)
- Stephanie Arnold
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King’s College London, London SE1 9NH, UK
| | - Sarah Watts
- CBR Division, Defence Science and Technology Laboratory, Salisbury SP4 0JQ, UK
| | - Emrys Kirkman
- CBR Division, Defence Science and Technology Laboratory, Salisbury SP4 0JQ, UK
| | - Clive P. Page
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King’s College London, London SE1 9NH, UK
| | - Simon C. Pitchford
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King’s College London, London SE1 9NH, UK
- Correspondence:
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Abstract
BACKGROUND Improvised explosive devices have resulted in a unique polytrauma injury pattern termed dismounted complex blast injury (DCBI), which is frequent in the modern military theater. Dismounted complex blast injury is characterized by extremity amputations, junctional vascular injury, and blast traumatic brain injury (bTBI). We developed a combat casualty relevant DCBI swine model, which combines hemorrhagic shock (HS) and tissue injury (TI) with a bTBI, to study interventions in this unique and devastating military injury pattern. METHODS A 50-kg male Yorkshire swine were randomized to the DCBI or SHAM group (instrumentation only). Those in the DCBI group were subjected to HS, TI, and bTBI. The blast injury was applied using a 55-psi shock tube wave. Tissue injury was created with bilateral open femur fractures. Hemorrhagic shock was induced by bleeding from femoral arteries to target pressure. A resuscitation protocol modified from the Tactical Combat Casualty Care guidelines simulated battlefield resuscitation for 240 minutes. RESULTS Eight swine underwent the DCBI model and five were allocated to the SHAM group. In the DCBI model the mean base excess achieved at the end of the HS shock was -8.57 ± 5.13 mmol·L -1 . A significant coagulopathy was detected in the DCBI model as measured by prothrombin time (15.8 seconds DCBI vs. 12.86 seconds SHAM; p = 0.02) and thromboelastography maximum amplitude (68.5 mm DCBI vs. 78.3 mm in SHAM; p = 0.0003). For the DCBI models, intracranial pressure (ICP) increased by a mean of 13 mm Hg, reaching a final ICP of 24 ± 7.7 mm Hg. CONCLUSION We created a reproducible large animal model to study the combined effects of severe HS, TI, and bTBI on coagulation and ICP in the setting of DCBI, with significant translational applications for the care of military warfighters. Within the 4-hour observational period, the swine developed a consistent coagulopathy with a concurrent brain injury evidenced by increasing ICP.
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Mistry S, Das A, Hardman JG, Bates DG, Scott TE. Pre-hospital continuous positive airway pressure after blast lung injury and hypovolaemic shock: a modelling study. Br J Anaesth 2021; 128:e151-e157. [PMID: 34863511 DOI: 10.1016/j.bja.2021.10.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 10/14/2021] [Accepted: 10/14/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND In non-traumatic respiratory failure, pre-hospital application of CPAP reduces the need for intubation. Primary blast lung injury (PBLI) accompanied by haemorrhagic shock is common after mass casualty incidents. We hypothesised that pre-hospital CPAP is also beneficial after PBLI accompanied by haemorrhagic shock. METHODS We performed a computer-based simulation of the cardiopulmonary response to PBLI followed by haemorrhage, calibrated from published controlled porcine experiments exploring blast injury and haemorrhagic shock. The effect of different CPAP levels was simulated in three in silico patients who had sustained mild, moderate, or severe PBLI (10%, 25%, 50% contusion of the total lung) plus haemorrhagic shock. The primary outcome was arterial partial pressure of oxygen (Pao2) at the end of each simulation. RESULTS In mild blast lung injury, 5 cm H2O ambient-air CPAP increased Pao2 from 10.6 to 12.6 kPa. Higher CPAP did not further improve Pao2. In moderate blast lung injury, 10 cm H2O CPAP produced a larger increase in Pao2 (from 8.5 to 11.1 kPa), but 15 cm H2O CPAP produced no further benefit. In severe blast lung injury, 5 cm H2O CPAP inceased Pao2 from 4.06 to 8.39 kPa. Further increasing CPAP to 10-15 cm H2O reduced Pao2 (7.99 and 7.90 kPa, respectively) as a result of haemodynamic impairment resulting from increased intrathoracic pressures. CONCLUSIONS Our modelling study suggests that ambient air 5 cm H2O CPAP may benefit casualties suffering from blast lung injury, even with severe haemorrhagic shock. However, higher CPAP levels beyond 10 cm H2O after severe lung injury reduced oxygen delivery as a result of haemodynamic impairment.
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Affiliation(s)
- Sonal Mistry
- School of Engineering, University of Warwick, Coventry, UK
| | - Anup Das
- School of Engineering, University of Warwick, Coventry, UK
| | - Jonathan G Hardman
- Anaesthesia and Critical Care, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK
| | - Declan G Bates
- School of Engineering, University of Warwick, Coventry, UK.
| | - Timothy E Scott
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, ICT Centre, Birmingham, UK.
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Early Maladaptive Cardiovascular Responses are Associated with Mortality in a Porcine Model of Hemorrhagic Shock. Shock 2021; 53:485-492. [PMID: 31274830 DOI: 10.1097/shk.0000000000001401] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Hemorrhage is a leading cause of death on the battlefield. Current methods for predicting hemodynamic deterioration during hemorrhage are of limited accuracy and practicality. During a study of the effects of remote ischemic preconditioning in pigs that underwent hemorrhage, we noticed arrhythmias among all pigs that died before the end of the experiment but not among surviving pigs. The present study was designed to identify and characterize the early maladaptive hemodynamic responses (tachycardia in the presence of hypotension without a corresponding increase in cardiac index or mean arterial blood pressure) and their predictive power for early mortality in this experimental model. METHODS Controlled hemorrhagic shock was induced in 16 pigs. Hemodynamic parameters were monitored continuously for 7 h following bleeding. Changes in cardiovascular and laboratory parameters were analyzed and compared between those that had arrhythmia and those that did not. RESULTS All animals had similar changes in parameters until the end of the bleeding phase. Six animals developed arrhythmias and died early, while 10 had no arrhythmias and survived longer than 6 h or until euthanasia. Unlike survivors, those that died did not compensate for cardiac output (CO), diastolic blood pressure (DBP), and stroke volume (SV). Oxygen delivery (DO2) and mixed venous saturation (SvO2) remained low in animals that had arrhythmia, while achieving certain measures of recuperation in animals that did not. Serum lactate increased earlier and continued to rise in all animals that developed arrhythmias. No significant differences in hemoglobin concentrations were observed between groups. CONCLUSIONS Despite similar initial changes in variables, we found that low CO, DBP, SV, DO2, SvO2, and high lactate are predictive of death in this animal model. The results of this experimental study suggest that maladaptive responses across a range of cardiovascular parameters that begin early after hemorrhage may be predictive of impending death, particularly in situations where early resuscitative treatment may be delayed.
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Wang H, Zhang W, Liu J, Gao J, Fang LE, Liu Z, Xia B, Fan X, Li C, Lu Q, Qian A. NF-κB and FosB mediate inflammation and oxidative stress in the blast lung injury of rats exposed to shock waves. Acta Biochim Biophys Sin (Shanghai) 2021; 53:283-293. [PMID: 33677486 DOI: 10.1093/abbs/gmaa179] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Indexed: 12/15/2022] Open
Abstract
Blast lung injury (BLI) is the major cause of death in explosion-derived shock waves; however, the mechanisms of BLI are not well understood. To identify the time-dependent manner of BLI, a model of lung injury of rats induced by shock waves was established by a fuel air explosive. The model was evaluated by hematoxylin and eosin staining and pathological score. The inflammation and oxidative stress of lung injury were also investigated. The pathological scores of rats' lung injury at 2 h, 24 h, 3 days, and 7 days post-blast were 9.75±2.96, 13.00±1.85, 8.50±1.51, and 4.00±1.41, respectively, which were significantly increased compared with those in the control group (1.13±0.64; P<0.05). The respiratory frequency and pause were increased significantly, while minute expiratory volume, inspiratory time, and inspiratory peak flow rate were decreased in a time-dependent manner at 2 and 24 h post-blast compared with those in the control group. In addition, the expressions of inflammatory factors such as interleukin (IL)-6, IL-8, FosB, and NF-κB were increased significantly at 2 h and peaked at 24 h, which gradually decreased after 3 days and returned to normal in 2 weeks. The levels of total antioxidant capacity, total superoxide dismutase, and glutathione peroxidase were significantly decreased 24 h after the shock wave blast. Conversely, the malondialdehyde level reached the peak at 24 h. These results indicated that inflammatory and oxidative stress induced by shock waves changed significantly in a time-dependent manner, which may be the important factors and novel therapeutic targets for the treatment of BLI.
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Affiliation(s)
- Hong Wang
- Lab for Bone Metabolism, Xi’an Key Laboratory of Special Medicine and Health Engineering, Key Lab for Space Biosciences and Biotechnology, Research Center for Special Medicine and Health Systems Engineering, NPU-UAB Joint Laboratory for Bone Metabolism, School of Life Sciences, Northwestern Polytechnical University, Xi’an 710072, China
- Research Center for Toxicological and Biological Effects, Institute for Hygiene of Ordnance Industry, Xi’an 710065, China
| | - Wenjuan Zhang
- Lab for Bone Metabolism, Xi’an Key Laboratory of Special Medicine and Health Engineering, Key Lab for Space Biosciences and Biotechnology, Research Center for Special Medicine and Health Systems Engineering, NPU-UAB Joint Laboratory for Bone Metabolism, School of Life Sciences, Northwestern Polytechnical University, Xi’an 710072, China
| | - Jinren Liu
- Research Center for Toxicological and Biological Effects, Institute for Hygiene of Ordnance Industry, Xi’an 710065, China
| | - Junhong Gao
- Research Center for Toxicological and Biological Effects, Institute for Hygiene of Ordnance Industry, Xi’an 710065, China
| | - L e Fang
- Department of Clinical Laboratory, 521 Hospital of Ordnance Industry, Xi’an 710065, China
| | - Zhiyong Liu
- Lab for Bone Metabolism, Xi’an Key Laboratory of Special Medicine and Health Engineering, Key Lab for Space Biosciences and Biotechnology, Research Center for Special Medicine and Health Systems Engineering, NPU-UAB Joint Laboratory for Bone Metabolism, School of Life Sciences, Northwestern Polytechnical University, Xi’an 710072, China
- Research Center for Toxicological and Biological Effects, Institute for Hygiene of Ordnance Industry, Xi’an 710065, China
| | - Baoqing Xia
- Research Center for Toxicological and Biological Effects, Institute for Hygiene of Ordnance Industry, Xi’an 710065, China
| | - Xiaolin Fan
- Research Center for Toxicological and Biological Effects, Institute for Hygiene of Ordnance Industry, Xi’an 710065, China
| | - Cunzhi Li
- Research Center for Toxicological and Biological Effects, Institute for Hygiene of Ordnance Industry, Xi’an 710065, China
| | - Qing Lu
- Research Center for Toxicological and Biological Effects, Institute for Hygiene of Ordnance Industry, Xi’an 710065, China
| | - Airong Qian
- Lab for Bone Metabolism, Xi’an Key Laboratory of Special Medicine and Health Engineering, Key Lab for Space Biosciences and Biotechnology, Research Center for Special Medicine and Health Systems Engineering, NPU-UAB Joint Laboratory for Bone Metabolism, School of Life Sciences, Northwestern Polytechnical University, Xi’an 710072, China
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Kheirabadi BS, Miranda N, Terrazas IB, Voelker AN, de Guzman R, Wienandt NA, Brown AW, Dubick MA. Should Albumin be Considered for Prehospital Resuscitation in Austere Environments? A Prospective Randomized Survival Study in Rabbits. Shock 2020; 54:358-367. [PMID: 31743300 DOI: 10.1097/shk.0000000000001480] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The new guidelines for prehospital care of combat casualties in shock recommend administration of whole blood or blood components to increase blood pressure to a permissible hypotensive level (i.e., hypotensive resuscitation [HR]). We investigated if 2 h of HR using limited volumes of whole blood, plasma, or albumin would lead to full recovery and long-term survival of rabbits subjected to severe hemorrhagic shock (HS). METHODS Following instrumentation, laparotomy was performed on IV-anesthetized spontaneously breathing New Zealand white rabbits (3.0 kg -3.5 kg). Next, ∼40% of rabbits' blood volume was removed producing HS (mean arterial pressure [MAP]∼20 mm Hg). Fifteen minutes later, rabbits were resuscitated with a limited volume (12.5 mL/kg) of rabbit whole blood (fresh whole blood [FWB]), rabbit fresh frozen plasma (FFP), or 5% human albumin (ALB) to a target pressure (MAP) of 60 mm Hg (n=8/grp) and monitored for 2 h. Liver bleeding time was measured at baseline and 10 min after HR. Subsequently, animals were fully resuscitated (blood + lactated Ringer [LR]), surgically repaired, and recovered for 8 days. An untreated group (n = 6) was also included. RESULTS Following HS, lactate and base deficit levels were increased to 8.2 ± 1.6 and 12.9 ± 3.1 mM respectively with no difference among groups. A lower volume of FWB volume was required to reach the target MAP (P < 0.05 vs. ALB) but MAP declined during the HR period (P < 0.01 vs. ALB). FWB provided higher hematocrit and platelets but it did not reduce lactate level faster than other fluids. Beside higher fibrinogen, no differences were found in hemostatic or resuscitative effects of FFP versus ALB. Bleeding time was prolonged with ALB and FFP fluids but unchanged with FWB. Untreated rabbits died during shock or shortly after. All treated rabbits except one recovered and lived for 8 days with normal blood tests and similar tissue histology. CONCLUSIONS Two hours of HR using a limited volume of FWB, FFP, or ALB led to full recovery and long-term survival of rabbits subjected to HS. Apart from bleeding time, no clinically significant differences were found among the three fluids. Five percent human albumin solutions are isotonic, iso-oncotic, ready-to-use, stable, and compatible with all blood types and should be considered for prehospital resuscitation where blood products are not available or not accepted.
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Management of primary blast lung injury: a comparison of airway pressure release versus low tidal volume ventilation. Intensive Care Med Exp 2020; 8:26. [PMID: 32577915 PMCID: PMC7309205 DOI: 10.1186/s40635-020-00314-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 06/04/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Primary blast lung injury (PBLI) presents as a syndrome of respiratory distress and haemoptysis resulting from explosive shock wave exposure and is a frequent cause of mortality and morbidity in both military conflicts and terrorist attacks. The optimal mode of mechanical ventilation for managing PBLI is not currently known, and clinical trials in humans are impossible due to the sporadic and violent nature of the disease. METHODS A high-fidelity multi-organ computational simulator of PBLI pathophysiology was configured to replicate data from 14 PBLI casualties from the conflict in Afghanistan. Adaptive and responsive ventilatory protocols implementing low tidal volume (LTV) ventilation and airway pressure release ventilation (APRV) were applied to each simulated patient for 24 h, allowing direct quantitative comparison of their effects on gas exchange, ventilatory parameters, haemodynamics, extravascular lung water and indices of ventilator-induced lung injury. RESULTS The simulated patients responded well to both ventilation strategies. Post 24-h investigation period, the APRV arm had similar PF ratios (137 mmHg vs 157 mmHg), lower sub-injury threshold levels of mechanical power (11.9 J/min vs 20.7 J/min) and lower levels of extravascular lung water (501 ml vs 600 ml) compared to conventional LTV. Driving pressure was higher in the APRV group (11.9 cmH2O vs 8.6 cmH2O), but still significantly less than levels associated with increased mortality. CONCLUSIONS Appropriate use of APRV may offer casualties with PBLI important mortality-related benefits and should be considered for management of this challenging patient group.
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Scott TE, Haque M, Das A, Cliff I, Bates DG, Hardman JG. Efficacy of continuous positive airway pressure in casualties suffering from primary blast lung injury: A modeling study. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2020; 2019:4965-4968. [PMID: 31946974 DOI: 10.1109/embc.2019.8857613] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Primary blast lung injury is the most important component of a multisystem syndrome of injury that results from exposure to an explosive shockwave. The majority of such casualties require ventilation in an intensive care unit. We describe the use of a novel primary blast lung injury simulator to evaluate the potential efficacy of continuous positive airway pressure in 6 in silico casualties over 24 hours after injury. Our results suggest that primary blast lung injury is a form of acute lung injury that can be effectively managed with continuous positive airway pressure. In austere environments or in circumstances where medical resources are overwhelmed, continuous positive airway pressure using ambient air may be of benefit.
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Impact of high-dose norepinephrine during intra-hospital damage control resuscitation of traumatic haemorrhagic shock: A propensity-score analysis. Injury 2020; 51:1164-1171. [PMID: 31791590 DOI: 10.1016/j.injury.2019.11.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 11/17/2019] [Accepted: 11/23/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The use of norepinephrine (NE) during uncontrolled haemorrhagic shock (HS) has mostly been investigated in experimental studies. Clinical data including norepinephrine dose and its impact on fluid resuscitation and organ function are scarce. We hypothesized that there is great variability in NE use and that high doses of NE could lead to increased organ dysfunction as measured by the sequential organ failure assessment (SOFA). METHOD We included patients with HS (systolic blood pressure < 90 mmHg in severely injured patients) who required haemostasis surgery and a transfusion of more than 4 packed red blood cells (PRBC) in the first 6 h of admission and the used of norepinephrine infusion to maintain the blood pressure goal, between admission and the end of haemostasis surgery in a prospective trauma database. A ROC curve determined that, using Youden's criterion, a dose of NE ≥ 0.6 µg/kg/min was the optimal threshold associated with intrahospital mortality. Patients were compared according to this threshold in a propensity score (PS) model. In a generalized linear mixed model, we searched for independent factors associated with a SOFA ≥ 9 at 24 h RESULTS: A total of 89 patients were analysed. Fluid infusion rate ranged from 1.43 to 57.9 mL/kg/h and norepinephrine infusion rate from 0.1 to 2.8 µg/kg/min. The HDNE group received significantly less fluid than the LDNE group. This dose is associated with a higher SOFA score at 24h: 9 (7-10) vs. 7 (6-9) (p = 0.003). Factors independently associated with a SOFA score ≥ 9 at 24 h were maximal norepinephrine rate ≥ 0.6 µg/kg/min (OR 6.69, 95% CI 1.82 - 25.54; p = 0.004), non-blood resuscitation volume < 9 mL/kg/h (OR 3.98, 95% CI 1.14 - 13.95; p = 0.031) and lactate at admission ≥ 5 mmol/L (OR 5.27, 95% CI 1.48 - 18.77; p = 0.010) CONCLUSION: High dose of norepinephrine infusion is associated with deleterious effects as attested by a higher SOFA score at 24 h and likely hypovolemia as measured by reduced non-blood resuscitation volume. We did not find any significant difference in mortality over the long term.
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Watts S, Smith JE, Gwyther R, Kirkman E. Closed chest compressions reduce survival in an animal model of haemorrhage-induced traumatic cardiac arrest. Resuscitation 2019; 140:37-42. [PMID: 31077754 DOI: 10.1016/j.resuscitation.2019.04.048] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 04/09/2019] [Accepted: 04/28/2019] [Indexed: 11/18/2022]
Abstract
Closed chest compressions (CCC) are recommended for medical cardiac arrest, but there is little evidence to support their inclusion for traumatic cardiac arrest (TCA). This laboratory study evaluated CCC following haemorrhage-induced TCA and whether resuscitation with blood improved survival compared to saline. The study was conducted with the authority of UK Animals (Scientific Procedures) Act 1986 (received institutional ethical approval and a Home Office Licence) using 39 terminally anesthetised, instrumented, juvenile Large White pigs. Following baseline measurements, animals underwent captive bolt injury to the right thigh and controlled haemorrhage (30% blood volume). Sixty minutes later there was a further haemorrhage to a MAP of 20 mmHg. The randomised resuscitation protocol was initiated within 5 min: CCC (Group 1); IV whole blood (Group 2); IV 0.9% saline (Group 3); IV whole blood + CCC (Group 4); and IV saline + CCC (Group 5). Fluid was administered as 3 × 10 ml/kg boluses using the Belmont® Rapid Infuser. The LUCAS™ II Chest Compression System delivered CCC. Primary Outcome was attainment of return of spontaneous circulation (ROSC MAP ≥ 50 mmHg) at Study End (fifteen minutes post-resuscitation) and secondary outcomes included haemodynamics. Mortality (MAP≤10 mmHg) was significantly higher in Group 1 compared to Groups 2 and 3 (P < 0.0001). Resuscitation with whole blood was significantly better than saline (P = 0.0069), no animals in Group 3 attained ROSC. The addition of chest compressions to fluid resuscitation resulted in a significantly worse outcome with saline resuscitation (P = 0.0023) but not with whole blood (P = 0.4411). Cardiovascular variables at the end of the Resuscitation Phase and Study End were significantly worse for Group 5 compared to Group 3. Some significant differences were present at the end of the Resuscitation Phase for Group 4 versus Group 2 but these differences were no longer present by Study End. CCC were associated with increased mortality and compromised haemodynamics compared to intravenous fluid resuscitation. Whole blood resuscitation was better than saline.
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Affiliation(s)
- Sarah Watts
- CBR Division, Dstl Porton Down, Salisbury, Wiltshire, SP4 0JQ, UK.
| | - Jason E Smith
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK; Emergency Department, Derriford Hospital, Plymouth, UK
| | - Robert Gwyther
- CBR Division, Dstl Porton Down, Salisbury, Wiltshire, SP4 0JQ, UK
| | - Emrys Kirkman
- CBR Division, Dstl Porton Down, Salisbury, Wiltshire, SP4 0JQ, UK
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Trauma Hemostasis and Oxygenation Research Network position paper on the role of hypotensive resuscitation as part of remote damage control resuscitation. J Trauma Acute Care Surg 2019; 84:S3-S13. [PMID: 29799823 DOI: 10.1097/ta.0000000000001856] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The Trauma Hemostasis and Oxygenation Research (THOR) Network has developed a consensus statement on the role of permissive hypotension in remote damage control resuscitation (RDCR). A summary of the evidence on permissive hypotension follows the THOR Network position on the topic. In RDCR, the burden of time in the care of the patients suffering from noncompressible hemorrhage affects outcomes. Despite the lack of published evidence, and based on clinical experience and expertise, it is the THOR Network's opinion that the increase in prehospital time leads to an increased burden of shock, which poses a greater risk to the patient than the risk of rebleeding due to slightly increased blood pressure, especially when blood products are available as part of prehospital resuscitation.The THOR Network's consensus statement is, "In a casualty with life-threatening hemorrhage, shock should be reversed as soon as possible using a blood-based HR fluid. Whole blood is preferred to blood components. As a part of this HR, the initial systolic blood pressure target should be 100 mm Hg. In RDCR, it is vital for higher echelon care providers to receive a casualty with sufficient physiologic reserve to survive definitive surgical hemostasis and aggressive resuscitation. The combined use of blood-based resuscitation and limiting systolic blood pressure is believed to be effective in promoting hemostasis and reversing shock".
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Garner J, Breeze J. Dispatches from the editor: blast injury is everyone's problem. J ROY ARMY MED CORPS 2018; 165:1-2. [PMID: 30514746 DOI: 10.1136/jramc-2018-001081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 09/25/2018] [Indexed: 11/03/2022]
Affiliation(s)
- Jeff Garner
- Department of Surgery, Rotherham NHS Foundation Trust, Sheffield, UK
| | - J Breeze
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
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Smith JE, Watts S, Spear AM, Wilson C, Kirkman E. Nebulised recombinant activated factor VII (rFVIIa) does not attenuate the haemorrhagic effects of blast lung injury. J ROY ARMY MED CORPS 2018; 165:51-56. [PMID: 30420554 PMCID: PMC6581091 DOI: 10.1136/jramc-2018-001029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 07/28/2018] [Accepted: 07/30/2018] [Indexed: 01/19/2023]
Abstract
Introduction Primary blast lung injury causes intrapulmonary haemorrhage. A number of case reports have suggested the efficacy of recombinant activated factor VII (rFVIIa) in the treatment of diffuse alveolar haemorrhage from a range of medical causes, but its efficacy in blast lung is unknown. The aim of this study was to investigate whether nebulised rFVIIa attenuates the haemorrhagic effects of blast lung injury in an animal model. Methods Terminally anaesthetised rabbits subjected to blast lung injury were randomised to receive either rFVIIa or placebo via a nebuliser. The primary outcome was the level of blood iron–transferrin complex, a marker of the extent of blast lung injury, analysed using low temperature electron paramagnetic resonance spectroscopy. Results Blast exposure led to a significant fall in iron-bound transferrin in both groups of animals (p<0.001), which remained depressed during the study. There were no significant differences in iron–transferrin between the rFVIIa and placebo treatment groups over the duration of the study (p=0.081), and there was no trend towards elevated iron–transferrin in the rFVIIa-treated group once drug treatment had started. There was suggestive evidence of systemic absorption of rFVIIa given via the inhaled route. Conclusion A single dose of nebulised rFVIIa did not attenuate pulmonary haemorrhage in a rabbit model of blast lung injury. As there was some evidence of systemic absorption, the inhaled route does not avoid the concern about potential thromboembolic complications from administration of rFVIIa.
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Affiliation(s)
- Jason E Smith
- CBR Division, Dstl Porton Down, Salisbury, UK.,Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
| | - S Watts
- CBR Division, Dstl Porton Down, Salisbury, UK
| | - A M Spear
- CBR Division, Dstl Porton Down, Salisbury, UK
| | - C Wilson
- CBR Division, Dstl Porton Down, Salisbury, UK
| | - E Kirkman
- CBR Division, Dstl Porton Down, Salisbury, UK
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Gauss T, Gayat E, Harrois A, Raux M, Follin A, Daban JL, Cook F, Hamada S, Attias A, Ausset S, Boutonnet M, Dhonneur G, Duranteau J, Langeron O, Mantz J, Paugam-Burtz C, Pirracchio R, Riou B, de St Maurice G, Vigué B, Bertho K, Chollet-Xemard C, Dolveck F, Michelland L, Reuter PG, Ricard-Hibon A, Richard O, Sapir D, Vivien B. Effect of early use of noradrenaline on in-hospital mortality in haemorrhagic shock after major trauma: a propensity-score analysis. Br J Anaesth 2018; 120:1237-1244. [DOI: 10.1016/j.bja.2018.02.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 01/19/2018] [Accepted: 03/01/2018] [Indexed: 10/17/2022] Open
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15
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Affiliation(s)
- Jeremy W Cannon
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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16
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Permissive hypotension versus conventional resuscitation strategies in adult trauma patients with hemorrhagic shock: A systematic review and meta-analysis of randomized controlled trials. J Trauma Acute Care Surg 2018; 84:802-808. [DOI: 10.1097/ta.0000000000001816] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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17
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Kemp Bohan P, Schreiber MA. Resuscitation. MANAGING DISMOUNTED COMPLEX BLAST INJURIES IN MILITARY & CIVILIAN SETTINGS 2018. [PMCID: PMC7122077 DOI: 10.1007/978-3-319-74672-2_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Blast injuries can produce complex patterns of injury and can easily result in hemorrhagic shock. Adequate resuscitation of blast-injured patients is critical, as both under- and over-resuscitation can result in a number of fatal complications. Consideration must be given to the choice of resuscitative fluid, the volume of resuscitation, the timing of resuscitation relative to definitive surgical management, and the determination of endpoints at which resuscitation can be stopped. This chapter explores resuscitation of blast-injured patients, beginning in the prehospital phase with initial choice of fluid and continuing through definitive resuscitation at a higher echelon of care. Particular consideration is given to the effect of resuscitation on the unique physiologic derangements seen following blast injury. Drawing upon the enormous amount of literature on resuscitation from the recent coalition experiences in Iraq and Afghanistan, we advocate for the use of early hemostatic resuscitation with a high ratio of plasma, platelets, and packed red blood cells, with a transition to resuscitation guided by viscoelastic testing or coagulation status immediately following definitive control of hemorrhage.
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CD43Lo classical monocytes participate in the cellular immune response to isolated primary blast lung injury. J Trauma Acute Care Surg 2017; 81:500-11. [PMID: 27306447 DOI: 10.1097/ta.0000000000001116] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Understanding of the cellular immune response to primary blast lung injury (PBLI) is limited, with only the neutrophil response well documented. Moreover, its impact on the immune response in distal organs remains poorly understood. In this study, a rodent model of isolated primary blast injury was used to investigate the acute cellular immune response to isolated PBLI in the circulation and lung, including the monocyte response, and investigate distal subacute immune effects in the spleen and liver 6 hours after injury. METHODS Rats were subjected to a shock wave (~135 kPa overpressure, 2 ms duration) inducing PBLI or sham procedure. Rat physiology was monitored, and at 1, 3, and 6 hours thereafter, blood, lung, and bronchoalveolar lavage fluid (BALF) were collected and analyzed by flow cytometry, enzyme-linked immunosorbent assay, and histologic examination. In addition, at 6 hours, spleen and liver were collected and analyzed by flow cytometry. RESULTS Lung histology confirmed pulmonary barotrauma and inflammation. This was associated with rises in CXCL-1, interleukin 6 (IL-6), tumor necrosis factor α and albumin protein in the BALF. Significant acute increases in blood and lung neutrophils and CD43Lo/His48Hi (classical) monocytes/macrophages were detected. No significant changes were seen in blood or lung "nonclassical" monocyte and in natural killler, B, or T cells. In the BALF, significant increases were seen in neutrophils, CD43Lo monocyte-macrophages and monocyte chemoattractant protein-1. Significant increases in CD43Lo and Hi monocyte-macrophages were detected in the spleen at 6 hours. CONCLUSION This study reveals a robust and selective response of CD43Lo/His48Hi (classical) monocytes, in addition to neutrophils, in blood and lung tissue following PBLI. An increase in monocyte-macrophages was also observed in the spleen at 6 hours. This profile of immune cells in the blood and BALF could present a new research tool for translational studies seeking to monitor, assess, or attenuate the immune response in blast-injured patients.
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Bjerkvig CK, Strandenes G, Eliassen HS, Spinella PC, Fosse TK, Cap AP, Ward KR. "Blood failure" time to view blood as an organ: how oxygen debt contributes to blood failure and its implications for remote damage control resuscitation. Transfusion 2017; 56 Suppl 2:S182-9. [PMID: 27100755 DOI: 10.1111/trf.13500] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Revised: 12/22/2015] [Accepted: 12/22/2015] [Indexed: 01/08/2023]
Abstract
Hemorrhagic shock is both a local and systemic disorder. In the context of systemic effects, blood loss may lead to levels of reduced oxygen delivery (DO2 ) sufficient to cause tissue ischemia. Similar to other physiologic debts such as sleep, it is not possible to incur a significant oxygen debt and suffer no consequences for lack of timely repayment. While the linkage between oxygen debt and traditional organ failure (renal, hepatic, lung, and circulation) has been long recognized, we should consider failure in two additional linked and very dynamic organ systems, the endothelium and blood. These systems are very sensitive to oxygen debt and at risk for failing, having further implications on all other organ systems. The degree of damage to the endothelium is largely modulated by the degree of oxygen debt. Thus hypoperfusion is believed to begin a cascade of events leading to acute traumatic coagulopathy (ATC). This combination of oxygen debt driven endothelial damage and ATC might be considered collectively as "blood failure" due to the highly connected networks between these drivers. This article presents the implications of oxygen debt for remote damage control resuscitation strategies, such as permissive hypotension and hemostatic resuscitation. We review the impact of whole blood resuscitation and red blood cell efficacy in mitigation of oxygen debt. At last, this article recognizes the need for simple and durable, lightweight equipment that can detect the adequacy of tissue DO2 and thus patient needs for resuscitative care. Point-of-care lactate measuring may be a predictive tool for identifying high-risk trauma patients and occult shock because it provides information beyond that of vital signs and mechanism of injury as it may help predict the level of oxygen debt accumulation and need for resuscitation. Serial measurements may also be valuable as a tool in guiding resuscitative efforts.
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Affiliation(s)
- Christopher K Bjerkvig
- Norwegian Naval Special Operations Command , Haukeland University Hospital, Bergen, Norway.,Department of Anesthesia and Intensive Care , Haukeland University Hospital, Bergen, Norway
| | - Geir Strandenes
- Norwegian Naval Special Operations Command , Haukeland University Hospital, Bergen, Norway.,Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | - Håkon S Eliassen
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | - Philip C Spinella
- Division of Pediatric Critical Care, Department of Pediatrics, Washington University in St Louis, St Louis, Missouri.,Coagulation and Blood Research, US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
| | - Theodor K Fosse
- Norwegian Naval Special Operations Command , Haukeland University Hospital, Bergen, Norway.,Department of Anesthesia and Intensive Care , Haukeland University Hospital, Bergen, Norway
| | - Andrew P Cap
- Blood Research Program, U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas
| | - Kevin R Ward
- Michigan Center for Integrative Research in Critical Care; Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan
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20
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Scott T, Kirkman E, Haque M, Gibb I, Mahoney P, Hardman J. Primary blast lung injury - a review. Br J Anaesth 2017; 118:311-316. [DOI: 10.1093/bja/aew385] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
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22
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Kudo D, Yoshida Y, Kushimoto S. Permissive hypotension/hypotensive resuscitation and restricted/controlled resuscitation in patients with severe trauma. J Intensive Care 2017; 5:11. [PMID: 34798698 PMCID: PMC8600688 DOI: 10.1186/s40560-016-0202-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Accepted: 12/17/2016] [Indexed: 11/10/2022] Open
Abstract
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.
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Scott T, Hulse E, Haque M, Kirkman E, Hardman J, Mahoney P. Modelling primary blast lung injury: current capability and future direction. J ROY ARMY MED CORPS 2016; 163:84-88. [PMID: 27881470 DOI: 10.1136/jramc-2016-000678] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 09/18/2016] [Accepted: 10/11/2016] [Indexed: 12/27/2022]
Abstract
Primary blast lung injury frequently complicates military conflict and terrorist attacks on civilian populations. The fact that it occurs in areas of conflict or unpredictable mass casualty events makes clinical study in human casualties implausible. Research in this field is therefore reliant on the use of some form of biological or non-biological surrogate model. This article briefly reviews the modelling work undertaken in this field until now and describes the rationale behind the generation of an in silico physiological model.
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Affiliation(s)
- Timothy Scott
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, ICT Centre, Birmingham, UK
| | - E Hulse
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, ICT Centre, Birmingham, UK
| | - M Haque
- Anaesthesia & Critical Care Research Group, Division of Clinical Neuroscience, Nottingham University Hospital, Queens Medical Centre, Nottingham, UK
| | - E Kirkman
- Defence Science and Technology Laboratories, Salisbury, UK
| | - J Hardman
- Anaesthesia & Critical Care Research Group, Division of Clinical Neuroscience, Nottingham University Hospital, Queens Medical Centre, Nottingham, UK
| | - P Mahoney
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, ICT Centre, Birmingham, UK
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25
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Hwang JE, Kim K, Lee JH, Jo YH, Kim J, Lee MJ, Park CJ. Blood pressure–targeted stepwise resuscitation of hemorrhagic shock in a swine model. J Surg Res 2016; 204:192-9. [DOI: 10.1016/j.jss.2016.04.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 02/01/2016] [Accepted: 04/14/2016] [Indexed: 11/29/2022]
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Evaluation of Prehospital Blood Products to Attenuate Acute Coagulopathy of Trauma in a Model of Severe Injury and Shock in Anesthetized Pigs. Shock 2016; 44 Suppl 1:138-48. [PMID: 26177017 PMCID: PMC4498650 DOI: 10.1097/shk.0000000000000409] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Acute trauma coagulopathy (ATC) is seen in 30% to 40% of severely injured casualties. Early use of blood products attenuates ATC, but the timing for optimal effect is unknown. Emergent clinical practice has started prehospital deployment of blood products (combined packed red blood cells and fresh frozen plasma [PRBCs:FFP], and alternatively PRBCs alone), but this is associated with significant logistical burden and some clinical risk. It is therefore imperative to establish whether prehospital use of blood products is likely to confer benefit. This study compared the potential impact of prehospital resuscitation with (PRBCs:FFP 1:1 ratio) versus PRBCs alone versus 0.9% saline (standard of care) in a model of severe injury. Twenty-four terminally anesthetised Large White pigs received controlled soft tissue injury and controlled hemorrhage (35% blood volume) followed by a 30-min shock phase. The animals were allocated randomly to one of three treatment groups during a 60-min prehospital evacuation phase: hypotensive resuscitation (target systolic arterial pressure 80 mmHg) using either 0.9% saline (group 1, n = 9), PRBCs:FFP (group 2, n = 9), or PRBCs alone (group 3, n = 6). Following this phase, an in-hospital phase involving resuscitation to a normotensive target (110 mmHg systolic arterial blood pressure) using PRBCs:FFP was performed in all groups. There was no mortality in any group. A coagulopathy developed in group 1 (significant increase in clot initiation and dynamics shown by TEG [thromboelastography] R and K times) that persisted for 60 to 90 min into the in-hospital phase. The coagulopathy was significantly attenuated in groups 2 and 3 (P = 0.025 R time and P = 0.035 K time), which were not significantly different from each other. Finally, the volumes of resuscitation fluid required was significantly greater in group 1 compared with groups 2 and 3 (P = 0.0067) (2.8 ± 0.3 vs. 1.9 ± 0.2 and 1.8 ± 0.3 L, respectively). This difference was principally due to a greater volume of saline used in group 1 (P = 0.001). Prehospital PRBCs:FFP or PRBCs alone may therefore attenuate ATC. Furthermore, the amount of crystalloid may be reduced with potential benefit of reducing the extravasation effect and later tissue edema.
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Abstract
It is more than 20 years since the term ‘Damage control’ was introduced to describe an emerging surgical strategy of abbreviated laparotomy for exsanguinating trauma patients. This strategy of temporisation and prioritisation of physiological recovery over completeness of anatomical repair was associated with improved survival in a subset of patients with combined major vascular and multiple visceral injuries. The ensuing years saw the rapid adoption of these principles as standard of care for massively injured and physiologically exhausted patients. Resuscitation of severely injured patients has changed significantly in the last decade with the emergence of a new resuscitation paradigm termed ‘damage control resuscitation’. Originating in combat support hospitals, damage control resuscitation emphasises the primacy of haemorrhage control while directly targeting the ‘lethal triad’ of coagulopathy, acidosis, and hypothermia. Integral to damage control resuscitation is the appropriate application of damage control surgery and together they constitute the modern damage control paradigm. This review aims to discuss the modern application of damage control resuscitation and damage control surgery and to review the evidence supporting its constituent components, as well as considering deficiencies in current knowledge and areas for future research.
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Affiliation(s)
- Patrick MacGoey
- East Midlands Major Trauma Centre, Queen’s Medical Centre, Nottingham, UK
| | - Christopher M Lamb
- East Midlands Major Trauma Centre, Queen’s Medical Centre, Nottingham, UK
| | - Alex P Navarro
- East Midlands Major Trauma Centre, Queen’s Medical Centre, Nottingham, UK
| | - Adam J Brooks
- East Midlands Major Trauma Centre, Queen’s Medical Centre, Nottingham, UK
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Abstract
In planning for future contingencies, current problems often crowd out historical perspective and planners often turn to technological solutions to bridge gaps between desired outcomes and the reality of recent experience. The US Military, North Atlantic Treaty Organization, and other allies are collectively taking stock of 10-plus years of medical discovery and rediscovery of combat casualty care after the wars in Iraq and Afghanistan. There has been undeniable progress in the treatment of combat wounded during the course of the conflicts in Southwest Asia, but continued efforts are required to improve hemorrhage control and provide effective prehospital resuscitation that treats both coagulopathy and shock. This article presents an appraisal of the recent evolution in medical practice in historical context and suggests how further gains in far forward resuscitation might be achieved using existing technology and methods based on whole-blood transfusion while research on new approaches continues.
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Egea-Guerrero JJ, Freire-Aragón MD, Serrano-Lázaro A, Quintana-Díaz M. Resuscitative goals and new strategies in severe trauma patient resuscitation. Med Intensiva 2014; 38:502-12. [PMID: 25241268 DOI: 10.1016/j.medin.2014.06.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 06/03/2014] [Accepted: 06/16/2014] [Indexed: 11/17/2022]
Abstract
Traumatic injuries represent a major health problem all over the world. In recent years we have witnessed profound changes in the paradigm of severe trauma patient resuscitation, new concepts regarding acute coagulopathy in trauma have been proposed, and there has been an expansion of specific commercial products related to hemostasis, among other aspects. New strategies in severe trauma management include the early identification of those injuries that are life threatening and require surgical hemostasis, tolerance of moderate hypotension, rational intravascular volume replacement, prevention of hypothermia, correction of acidosis, optimization of oxygen carriers, and identification of those factors required by the patient (fresh frozen plasma, platelets, tranexamic acid, fibrinogen, cryoprecipitates and prothrombin complex). However, despite such advances, further evidence is required to improve survival rates in severe trauma patients.
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Affiliation(s)
- J J Egea-Guerrero
- Unidad de Neurocríticos. Hospital Universitario Virgen del Rocío, Sevilla, España; Instituto de Biomedicina (IBiS)/CSIC Universidad de Sevilla, Sevilla, España.
| | - M D Freire-Aragón
- Unidad de Neurocríticos. Hospital Universitario Virgen del Rocío, Sevilla, España
| | - A Serrano-Lázaro
- Unidad de Cuidados Intensivos, Hospital Clínico Universitario de Valencia, Valencia, España
| | - M Quintana-Díaz
- Unidad de Cuidados Intensivos, Hospital Universitario de La Paz, Madrid, España
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Abstract
Trauma is the leading cause of death during the first four decades of life in the developed countries. Its haemodynamic response underpins the patient's initial ability to survive, and the response to treatment and subsequent morbidity and resolution. Trauma causes a number of insults including haemorrhage, tissue injury (nociception) and, predominantly, in military casualties, blast from explosions. This article discusses aspects of the haemodynamic responses to these insults and subsequent treatment. 'Simple' haemorrhage (blood loss without significant volume of tissue damage) causes a biphasic response: mean arterial blood pressure (MBP) is initially maintained by the baroreflex (tachycardia and increased vascular resistance, Phase 1), followed by a sudden decrease in MAP initiated by a second reflex (decrease in vascular resistance and bradycardia, Phase 2). Phase 2 may be protective. The response to tissue injury attenuates Phase 2 and may cause a deleterious haemodynamic redistribution that compromises blood flow to some vital organs. In contrast, thoracic blast exposure augments Phase 2 of the response to haemorrhage. However, hypoxaemia from lung injury limits the effectiveness of hypotensive resuscitation by augmenting the attendant shock state. An alternative strategy ('hybrid resuscitation') whereby tissue perfusion is increased after the first hour of hypotensive resuscitation by adopting a revised normotensive target may ameliorate these problems. Finally, morphine also attenuates Phase 2 of the response to haemorrhage in some, but not all, species and this is associated with poor outcome. The impact on human patients is currently unknown and is the subject of a current physiological investigation.
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Affiliation(s)
- E Kirkman
- Biomedical Sciences Department, Defence Science and Technology Laboratory, Porton Down, Salisbury, UK
| | - S Watts
- Biomedical Sciences Department, Defence Science and Technology Laboratory, Porton Down, Salisbury, UK
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Abstract
The Combat Casualty Care research programme is an integrated suite of projects designed to address Defence Medical Services' research needs for casualty care. The programme covers a broad spectrum of topics ranging from the pathophysiological and immunological impact of military relevant injuries to the effects of these disturbances on the response to early treatment. Dstl Porton Down has a long history of studying military injuries and has developed models, both in vivo and physical, to address the research needs. The work is conducted in close collaboration with clinical colleagues at the Royal Centre for Defence Medicine who have direct experience of the clinical issues faced by combat casualties and insights into the potential clinical implications of emerging strategies. This article reviews progress in research areas spanning forward resuscitation, with a particular focus on blast-related injuries, trauma coagulopathy, effects of drugs on the response to haemorrhage and deployed research. A significant 'value added' component has been the underpinning of higher degrees for seconded military clinicians at Dstl Porton Down who have made a valuable contribution to the overall programme.
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Affiliation(s)
- Emrys Kirkman
- Biomedical Sciences Department, Dstl Porton Down, Salisbury, UK
| | - S Watts
- Biomedical Sciences Department, Dstl Porton Down, Salisbury, UK
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Palmer L, Martin L. Traumatic coagulopathy--part 2: Resuscitative strategies. J Vet Emerg Crit Care (San Antonio) 2014; 24:75-92. [PMID: 24393363 DOI: 10.1111/vec.12138] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Accepted: 11/10/2013] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To discuss the current resuscitative strategies for trauma-induced hemorrhagic shock and acute traumatic coagulopathy (ATC). ETIOLOGY Hemorrhagic shock can be acutely fatal if not immediately and appropriately treated. The primary tenets of hemorrhagic shock resuscitation are to arrest hemorrhage and restore the effective circulating volume. Large volumes of isotonic crystalloids have been the resuscitative strategy of choice; however, data from experimental animal models and retrospective human analyses now recognize that large-volume fluid resuscitation in uncontrolled hemorrhage may be deleterious. The optimal resuscitative strategy has yet to be defined. In human trauma, implementing damage control resuscitation with damage control surgery for controlling ongoing hemorrhage, acidosis, and hypothermia; managing ATC; and restoring effective circulating volume is emerging as a more optimal resuscitative strategy. With hyperfibrinolysis playing an integral role in the manifestation of ATC, the use of antifibrinolytics (eg, tranexamic acid and aminocaproic acid) may also serve a beneficial role in the early posttraumatic period. Considering the sparse information regarding these resuscitative techniques in veterinary medicine, veterinarians are left with extrapolating information from human trials and experimental animal models. DIAGNOSIS Viscoelastic tests integrated with predictive scoring systems may prove to be the most reliable methods for early detection of ATC as well as for guiding transfusion requirements. SUMMARY Hemorrhage accounts for up to 40% of human trauma-related deaths and remains the leading cause of preventable death in human trauma. The exact proportion of trauma-related deaths due to exsanguinations in veterinary patients remains uncertain. Survivability depends upon achieving rapid definitive hemostasis, early attenuation of posttraumatic coagulopathy, and timely restoration of effective circulating volume. Early institution of damage control resuscitation in severely injured patients with uncontrolled hemorrhage has the ability to curtail posttraumatic coagulopathy and the exacerbation of metabolic acidosis and hypothermia and improve survival until definitive hemostasis is achieved.
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Affiliation(s)
- Lee Palmer
- Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, Auburn, AL 36849
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Eardley WGP, Watts SA, Clasper JC. Modelling for conflict: the legacy of ballistic research and current extremity in vivo modelling. J ROY ARMY MED CORPS 2013; 159:73-83. [PMID: 23720587 DOI: 10.1136/jramc-2013-000074] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Extremity ballistic injury is unique and the literature intended to guide its management is commonly misinterpreted. In order to care for those injured in conflict and conduct appropriate research, clinicians must be able to identify key in vivo studies, understand their weaknesses and desist the propagation of miscited and misunderstood ballistic dogma. This review provides the only inclusive critical overview of key studies of relevance to military extremity injury. In addition, the non-ballistic studies of limb injury, stabilisation and contamination that will form the basis from which future small animal extremity studies are constructed are presented. With an awareness of the legacy of military wound models and an insight into available generic models of extremity injury and contamination, research teams are well placed to optimise future military extremity injury management.
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Affiliation(s)
- William G P Eardley
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, ICT Centre, Institute of Research and Development, Birmingham, UK.
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David JS, Spann C, Marcotte G, Reynaud B, Fontaine O, Lefèvre M, Piriou V. Haemorrhagic shock, therapeutic management. ACTA ACUST UNITED AC 2013; 32:497-503. [PMID: 23896213 DOI: 10.1016/j.annfar.2013.07.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The management of a patient in post-traumatic haemorrhagic shock will meet different logics that will apply from the prehospital setting. This implies that the patient has beneficiated from a "Play and Run" prehospital strategy and was sent to a centre adapted to his clinical condition capable of treating all haemorrhagic lesions. The therapeutic goals will be to control the bleeding by early use of tourniquet, pelvic girdle, haemostatic dressing, and after admission to the hospital, the implementation of surgical and/or radiological techniques, but also to address all the factors that will exacerbate bleeding. These factors include hypothermia, acidosis and coagulopathy. The treatment of these contributing factors will be associated to concepts of low-volume resuscitation and permissive hypotension into a strategy called "Damage Control Resuscitation". Thus, the objective in situation of haemorrhagic shock will be to not exceed a systolic blood pressure of 90 mmHg (in the absence of severe head trauma) until haemostasis is achieved.
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Affiliation(s)
- J-S David
- Department of Anaesthesia and Intensive Care, Lyon Sud Hospital, Hospices Civils de Lyon, 69495 Pierre-Bénite cedex, France.
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Abstract
PURPOSE OF REVIEW Severe trauma is associated with hemorrhage, coagulopathy and transfusion of blood and blood products, all associated with considerable mortality and morbidity. The aim of this review is to focus on resuscitation, transfusion strategies and the management of bleeding in trauma as well as to emphasize on why coagulation has to be monitored closely and to discuss the rationale of modern and future transfusion strategies. RECENT FINDINGS Coagulopathy and uncontrolled bleeding remain leading causes of death in trauma, lead to blood transfusions and increased mortality as it has been recently shown that blood transfusion per se results in an adverse outcome. In the last years, damage control resuscitation, a combination of permissive hypotension, hemostatic resuscitation and damage control surgery, has been introduced to treat severely traumatized patients in hemorrhagic shock. Goals of treatment in trauma patients remain avoiding metabolic acidosis, hypothermia, treating coagulopathy and stabilizing the patient as soon as possible. The place of colloids and crystalloids in trauma resuscitation as well as the role of massive transfusion protocols with a certain FFP : RBC ratio and even platelets have to be reevaluated. SUMMARY Close monitoring of bleeding and coagulation in trauma patients allows goal-directed transfusions and thereby optimizes the patient's coagulation, reduces the exposure to blood products, reduces costs and may improve clinical outcome.
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Wang Y, Pan L, Fan W, Zhou Z, Zhu L, Wang Y, Hu R. Influence of vagal injury on acute traumatic reaction after blast injury. Eur J Trauma Emerg Surg 2013; 39:385-92. [PMID: 26815399 DOI: 10.1007/s00068-013-0277-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Accepted: 03/12/2013] [Indexed: 10/27/2022]
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MRI assessment of cerebral blood flow after experimental traumatic brain injury combined with hemorrhagic shock in mice. J Cereb Blood Flow Metab 2013; 33:129-36. [PMID: 23072750 PMCID: PMC3597358 DOI: 10.1038/jcbfm.2012.145] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Secondary insults such as hypotension or hemorrhagic shock (HS) can greatly worsen outcome after traumatic brain injury (TBI). We recently developed a mouse combined injury model of TBI and HS using a controlled cortical impact (CCI) model and showed that 90 minutes of HS can exacerbate neuronal death in hippocampus beneath the contusion. This combined injury model has three clinically relevant phases, a shock, pre hospital, and definitive care phases. Mice were randomly assigned to four groups, shams as well as a CCI only, an HS only, and a CCI+HS groups. The CCI and HS reduced cerebral blood flow (CBF) in multiple regions of interest (ROIs) in the hemisphere ipsilateral and contralateral to injury. Hemorrhagic shock to a level of ∼30 mm Hg exacerbated the CCI-induced CBF reductions in multiple ROIs ipsilateral to injury (hemisphere and thalamus) and in the hemisphere contralateral to injury (hemisphere, thalamus, hippocampus, and cortex, all P<0.05 versus CCI only, HS only or both). An important effect of HS duration was also seen after CCI with maximal CBF reduction seen at 90 minutes (P<0.0001 group-time effect in ipsilateral hippocampus). Given that neuronal death in hippocampus is exacerbated by 90 minutes of HS in this model, our data suggest an important role for exacerbation of posttraumatic ischemia in mediating the secondary injury in CCI plus HS. In conclusion, the serial, non invasive assessment of CBF using ASL-MRI (magnetic resonance imaging with arterial spin labeling) is feasible in mice even in the complex setting of combined CCI+HS. The impact of resuscitation therapies and various mutant mouse strains on CBF and other outcomes merits investigation in this model.
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Hemerka JN, Wu X, Dixon CE, Garman RH, Exo JL, Shellington DK, Blasiole B, Vagni VA, Janesko-Feldman K, Xu M, Wisniewski SR, Bayır H, Jenkins LW, Clark RSB, Tisherman SA, Kochanek PM. Severe brief pressure-controlled hemorrhagic shock after traumatic brain injury exacerbates functional deficits and long-term neuropathological damage in mice. J Neurotrauma 2012; 29:2192-208. [PMID: 22738159 DOI: 10.1089/neu.2011.2303] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Hypotension after traumatic brain injury (TBI) worsens outcome. We published the first report of TBI plus hemorrhagic shock (HS) in mice using a volume-controlled approach and noted increased neuronal death. To rigorously control blood pressure during HS, a pressure-controlled HS model is required. Our hypothesis was that a brief, severe period of pressure-controlled HS after TBI in mice will exacerbate functional deficits and neuropathology versus TBI or HS alone. C57BL6 male mice were randomized into four groups (n=10/group): sham, HS, controlled cortical impact (CCI), and CCI+HS. We used a pressure-controlled shock phase (mean arterial pressure [MAP]=25-27 mm Hg for 35 min) and its treatment after mild to moderate CCI including, a 90 min pre-hospital phase, during which lactated Ringer's solution was given to maintain MAP >70 mm Hg, and a hospital phase, when the shed blood was re-infused. On days 14-20, the mice were evaluated in the Morris water maze (MWM, hidden platform paradigm). On day 21, the lesion and hemispheric volumes were quantified. Neuropathology and hippocampal neuron counts (hematoxylin and eosin [H&E], Fluoro-Jade B, and NeuN) were evaluated in the mice (n=60) at 24 h, 7 days, or 21 days (n=5/group/time point). HS reduced MAP during the shock phase in the HS and CCI+HS groups (p<0.05). Fluid requirements during the pre-hospital phase were greatest in the CCI+HS group (p<0.05), and were increased in HS versus sham and CCI animals (p<0.05). MWM latency was increased on days 14 and 15 after CCI+HS (p<0.05). Swim speed and visible platform latency were impaired in the CCI+HS group (p<0.05). CCI+HS animals had increased contusion volume versus the CCI group (p<0.05). Hemispheric volume loss was increased 33.3% in the CCI+HS versus CCI group (p<0.05). CA1 cell loss was seen in CCI+HS and CCI animals at 24 h and 7 days (p<0.05). CA3 cell loss was seen after CCI+HS (p<0.05 at 24 h and 7 days). CA1 cell loss at 21 days was seen only in CCI+HS animals (p<0.05). Brief, severe, pressure-controlled HS after CCI produces robust functional deficits and exacerbates neuropathology versus CCI or HS alone.
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Affiliation(s)
- Joseph N Hemerka
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Schmidt BM, Rezende-Neto JB, Andrade MV, Winter PC, Carvalho MG, Lisboa TA, Rizoli SB, Cunha-Melo JR. Permissive hypotension does not reduce regional organ perfusion compared to normotensive resuscitation: animal study with fluorescent microspheres. World J Emerg Surg 2012; 7 Suppl 1:S9. [PMID: 23531188 PMCID: PMC3424975 DOI: 10.1186/1749-7922-7-s1-s9] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Introduction The objective of this study was to investigate regional organ perfusion acutely following uncontrolled hemorrhage in an animal model that simulates a penetrating vascular injury and accounts for prehospital times in urban trauma. We set forth to determine if hypotensive resuscitation (permissive hypotension) would result in equivalent organ perfusion compared to normotensive resuscitation. Methods Twenty four (n=24) male rats randomized to 4 groups: Sham, No Fluid (NF), Permissive Hypotension (PH) (60% of baseline mean arterial pressure - MAP), Normotensive Resuscitation (NBP). Uncontrolled hemorrhage caused by a standardised injury to the abdominal aorta; MAP was monitored continuously and lactated Ringer’s was infused. Fluorimeter readings of regional blood flow of the brain, heart, lung, kidney, liver, and bowel were obtained at baseline and 85 minutes after hemorrhage, as well as, cardiac output, lactic acid, and laboratory tests; intra-abdominal blood loss was assessed. Analysis of variance was used for comparison. Results Intra-abdominal blood loss was higher in NBP group, as well as, lower hematocrit and hemoglobin levels. No statistical differences in perfusion of any organ between PH and NBP groups. No statistical difference in cardiac output between PH and NBP groups, as well as, in lactic acid levels between PH and NBP. NF group had significantly higher lactic acidosis and had significantly lower organ perfusion. Conclusions Hypotensive resuscitation causes less intra-abdominal bleeding than normotensive resuscitation and concurrently maintains equivalent organ perfusion. No fluid resuscitation reduces intra-abdominal bleeding but also significantly reduces organ perfusion.
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Affiliation(s)
- Bruno M Schmidt
- Federal University of Minas Gerais, Av, Prof, Alfredo Balena 190, Belo Horizonte, MG, 30130-100, Brazil.
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Curry N, Davis PW. What's new in resuscitation strategies for the patient with multiple trauma? Injury 2012; 43:1021-8. [PMID: 22487163 DOI: 10.1016/j.injury.2012.03.014] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Revised: 12/22/2011] [Accepted: 03/11/2012] [Indexed: 02/02/2023]
Abstract
The last decade has seen a sea change in the management of major haemorrhage following traumatic injury. Damage control resuscitation (DCR), a strategy combining the techniques of permissive hypotension, haemostatic resuscitation and damage control surgery has been widely adopted as the preferred method of resuscitation in patients with haemorrhagic shock. The over-riding goals of DCR are to mitigate metabolic acidosis, hypothermia and coagulopathy and stabilise the patient as early as possible in a critical care setting. This narrative review examines the background to these changes in resuscitation practice, discusses the central importance of traumatic coagulopathy in driving these changes particularly in relation to the use of high FFP:RBC ratio and explores methods of predicting, diagnosing and treating the coagulopathy with massive transfusion protocols as well as newer coagulation factor concentrates. We discuss other areas of trauma haemorrhage management including the role of hypertonic saline and interventional radiology. Throughout this review we specifically examine whether the available evidence supports these newer practices.
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Affiliation(s)
- N Curry
- NHS Blood and Transplant, Oxford Radcliffe Hospitals NHS Trust and University of Oxford, UK.
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Housden S. Blast injury: A case study. Int Emerg Nurs 2012; 20:173-8. [DOI: 10.1016/j.ienj.2011.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2011] [Revised: 09/05/2011] [Accepted: 09/06/2011] [Indexed: 11/29/2022]
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Abstract
BACKGROUND Acute trauma coagulopathy in seriously injured casualties may be initiated by tissue hypoperfusion. A targeted (or novel hybrid [NH]) resuscitation strategy was developed to overcome poor tissue oxygen delivery associated with prolonged hypotension. METHODS Under the Animals (Scientific Procedures) Act 1986, terminally anesthetized large white pigs were divided into four groups (n = 6). Groups 1 and 2 received blast injury and 3 and 4 no blast (sham). All were given a controlled hemorrhage (35% blood volume) and an uncompressed grade IV liver injury. Five minutes later, all were resuscitated with 0.9% saline to a systolic arterial pressure (SAP) of 80 mm Hg. After 60 minutes, the NH groups (1 and 3) were resuscitated to a SAP (110 mm Hg), whereas hypotensive groups (2 and 4) continued with SAP 80 mm Hg for up to 8 hours from onset of resuscitation. RESULTS Mean survival time was shorter in group 2 (258 minutes) compared with groups 1, 3, and 4 (452 minutes, 448 minutes, and 369 minutes). By the end of the study, hypotension was associated with a significantly greater prothrombin time (1.73 ± 0.10 and 1.87 ± 0.15 times presurgery, groups 2 and 4) compared with NH (1.44 ± 0.09 and 1.36 ± 0.06, groups 1 and 3, p = 0.001). Blast versus sham had no significant effect on prothrombin time (p = 0.56). Peak levels of interleukin 6 were significantly lower in NH groups. Arterial base excess was significantly lower with hypotension (-18.4 mmol/L ± 2.7 mmol/L and -12.1 mmol/L ± 3.2 mmol/L) versus NH (-3.7 mmol/L ± 2.8 mmol/L and -1.8 mmol/L ± 1.8 mmol/L, p = 0.0001). Hematocrit was not significantly different between groups (p = 0.16). CONCLUSION Targeted resuscitation (NH) attenuates the development of acute trauma coagulopathy and systemic inflammation with improved tissue perfusion and reduced metabolic acidosis in a model of complex injury. This emphasizes the challenge of choosing a resuscitation strategy for trauma patients where the needs of tissue perfusion must be balanced against the risk of rebleeding during resuscitation.
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Meißner A, Schlenke P. Massive Bleeding and Massive Transfusion. Transfus Med Hemother 2012; 39:73-84. [PMID: 22670125 PMCID: PMC3364037 DOI: 10.1159/000337250] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2011] [Accepted: 02/03/2012] [Indexed: 01/25/2023] Open
Abstract
Massive bleeding in trauma patients is a serious challenge for all clinicians, and an interdisciplinary diagnostic and therapeutic approach is warranted within a limited time frame. Massive transfusion usually is defined as the transfusion of more than 10 units of packed red blood cells (RBCs) within 24 h or a corresponding blood loss of more than 1- to 1.5-fold of the body's entire blood volume. Especially male trauma patients experience this life-threatening condition within their productive years of life. An important parameter for clinical outcome is to succeed in stopping the bleeding preferentially within the first 12 h of hospital admission. Additional coagulopathy in the initial phase is induced by trauma itself and aggravated by consumption and dilution of clotting factors. Although different aspects have to be taken into consideration when viewing at bleedings induced by trauma compared to those caused by major surgery, the basic strategy is similar. Here, we will focus on trauma-induced massive hemorrhage. Currently there are no definite, worldwide accepted algorithms for blood transfusion and strategies for optimal coagulation management. There is increasing evidence that a higher ratio of plasma and RBCs (e.g. 1:1) endorsed by platelet transfusion might result in a superior survival of patients at risk for trauma-induced coagulopathy. Several strategies have been evolved in the military environment, although not all strategies should be transferred unproven to civilian practice, e.g. the transfusion of whole blood. Several agents have been proposed to support the restoration of coagulation. Some have been used for years without any doubt on their benefit-to-risk profile, whereas great enthusiasm of other products has been discouraged by inefficacy in terms of blood transfusion requirements and mortality or significant severe side effects. This review surveys current literature on fluid resuscitation, blood transfusion, and hemostatic agents currently used during massive hemorrhage in order to optimize patients' blood and coagulation management in emergency medical aid.
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Affiliation(s)
- Andreas Meißner
- Klinik für Anästhesie, Intensiv-und Notfallmedizin, Schmerztherapie und Palliativmedizin, Klinikum Stadt Soest, Germany
| | - Peter Schlenke
- Institut für Transfusionsmedizin und Transplantationsimmunologie, Universitätsklinikum Münster, Germany
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Early coagulopathy resulted from brain injury rather than hypoperfusion. ACTA ACUST UNITED AC 2011; 70:765; author reply 765-6. [PMID: 21610377 DOI: 10.1097/ta.0b013e318206d12a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Owers C, Morgan J, Garner JP. Authors' reply: abdominal trauma in primary blast injury ( Br J Surg 2011; 98: 168–179). Br J Surg 2011. [DOI: 10.1002/bjs.7611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- C Owers
- Department of General Surgery, Rotherham General Hospital, Rotherham, UK
| | - J Morgan
- Department of General Surgery, Rotherham General Hospital, Rotherham, UK
| | - J P Garner
- Department of General Surgery, Rotherham General Hospital, Rotherham, UK
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Midwinter MJ, Woolley T. Resuscitation and coagulation in the severely injured trauma patient. Philos Trans R Soc Lond B Biol Sci 2011; 366:192-203. [PMID: 21149355 DOI: 10.1098/rstb.2010.0220] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Developments in the resuscitation of the severely injured trauma patient in the last decade have been through the increased understanding of the early pathophysiological consequences of injury together with some observations and experiences of recent casualties of conflict. In particular, the recognition of early derangements of haemostasis with hypocoagulopathy being associated with increased mortality and morbidity and the prime importance of tissue hypoperfusion as a central driver to this process in this population of patients has led to new resuscitation strategies. These strategies have focused on haemostatic resuscitation and the development of the ideas of damage control resuscitation and damage control surgery continuum. This in turn has led to a requirement to be able to more closely monitor the physiological status, of major trauma patients, including their coagulation status, and react in an anticipatory fashion.
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Affiliation(s)
- Mark J Midwinter
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
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48
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Kirkman E, Watts S, Cooper G. Blast injury research models. Philos Trans R Soc Lond B Biol Sci 2011; 366:144-59. [PMID: 21149352 DOI: 10.1098/rstb.2010.0240] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Blast injuries are an increasing problem in both military and civilian practice. Primary blast injury to the lungs (blast lung) is found in a clinically significant proportion of casualties from explosions even in an open environment, and in a high proportion of severely injured casualties following explosions in confined spaces. Blast casualties also commonly suffer secondary and tertiary blast injuries resulting in significant blood loss. The presence of hypoxaemia owing to blast lung complicates the process of fluid resuscitation. Consequently, prolonged hypotensive resuscitation was found to be incompatible with survival after combined blast lung and haemorrhage. This article describes studies addressing new forward resuscitation strategies involving a hybrid blood pressure profile (initially hypotensive followed later by normotensive resuscitation) and the use of supplemental oxygen to increase survival and reduce physiological deterioration during prolonged resuscitation. Surprisingly, hypertonic saline dextran was found to be inferior to normal saline after combined blast injury and haemorrhage. New strategies have therefore been developed to address the needs of blast-injured casualties and are likely to be particularly useful under circumstances of enforced delayed evacuation to surgical care.
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Affiliation(s)
- E Kirkman
- Biomedical Sciences, Dstl Porton Down, Salisbury SP4 0JQ, UK
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Abstract
BACKGROUND Blast injury is uncommon, and remains poorly understood by most clinicians outside regions of active warfare. Primary blast injury (PBI) results from the interaction of the blast wave with the body, and typically affects gas-containing organs such as the ear, lungs and gastrointestinal tract. This review investigates the mechanisms and injuries sustained to the abdomen following blast exposure. METHODS MEDLINE was searched using the keywords 'primary blast injury', 'abdominal blast' and 'abdominal blast injury' to identify English language reports of abdominal PBI. Clinical reports providing sufficient data were used to calculate the incidence of abdominal PBI in hospitalized survivors of air blast, and in open- and enclosed-space detonations. RESULTS Sixty-one articles were identified that primarily reported clinical or experimental abdominal PBI. Nine clinical reports provided sufficient data to calculate an incidence of abdominal PBI; 31 (3·0 per cent) of 1040 hospitalized survivors of air blast suffered abdominal PBI, the incidence ranging from 1·3 to 33 per cent. The incidence for open- and enclosed-space detonations was 5·6 and 6·7 per cent respectively. The terminal ileum and caecum were the most commonly affected organs. Surgical management of abdominal PBI is similar to that of abdominal trauma of other causes. CONCLUSION Abdominal PBI is uncommon but has the potential for significant mortality and morbidity, which may present many days after blast exposure. It is commoner after blast in enclosed spaces and under water.
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Affiliation(s)
- C Owers
- Department of General Surgery, Rotherham NHS Foundation Trust, Moorgate Road, Rotherham S60 2UD, UK
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Experimental trauma models: an update. J Biomed Biotechnol 2011; 2011:797383. [PMID: 21331361 PMCID: PMC3035380 DOI: 10.1155/2011/797383] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2010] [Accepted: 12/17/2010] [Indexed: 01/31/2023] Open
Abstract
Treatment of polytrauma patients remains a medical as well as socioeconomic challenge. Although diagnostics and therapy improved during the last decades, multiple injuries are still the major cause of fatalities in patients below 45 years of age. Organ dysfunction and organ failure are major complications in patients with major injuries and contribute to mortality during the clinical course. Profound understanding of the systemic pathophysiological response is crucial for innovative therapeutic approaches. Therefore, experimental studies in various animal models are necessary. This review is aimed at providing detailed information of common trauma models in small as well as in large animals.
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