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Deluca A, Deininger C, Wichlas F, Traweger A, Lefering R, Mueller EJ. [Prehospital management in trauma patients and the increasing number of helicopter EMS transportations : An epidemiological study of the TraumaRegister DGU®]. Unfallchirurgie (Heidelb) 2024; 127:117-125. [PMID: 37395835 PMCID: PMC10834560 DOI: 10.1007/s00113-023-01337-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/27/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND/OBJECTIVE To compare the prehospital treatment modalities and intervention regimens for major trauma patients with comparable injury patterns between Austria and Germany. PATIENTS AND METHODS This analysis is based on data retrieved from the TraumaRegister DGU®. Data included severely injured trauma patients with an injury severity score (ISS) ≥ 16, an age ≥ 16 years, and who were primarily admitted to an Austrian (n = 4186) or German (n = 41,484) level I trauma center (TC) from 2008 to 2017. Investigated endpoints included prehospital times and interventions performed until final hospital admission. RESULTS The cumulative time for transportation from the site of the accident to the hospital did not significantly differ between the countries (62 min in Austria, 65 min in Germany). Overall, 53% of all trauma patients in Austria were transported to the hospital with a helicopter compared to 37% in Germany (p < 0.001). The rate of intubation was 48% in both countries, the number of chest tubes placed (5.7% Germany, 4.9% Austria), and the frequency of administered catecholamines (13.4% Germany, 12.3% Austria) were comparable (Φ = 0.00). Hemodynamic instability (systolic blood pressure, BP ≤ 90 mmHg) upon arrival in the TC was higher in Austria (20.6% vs. 14.7% in Germany; p < 0.001). A median of 500 mL of fluid was administered in Austria, whereas in Germany 1000 mL was infused (p < 0.001). Patient demographics did not reveal a relationship (Φ = 0.00) between both countries, and the majority of patients sustained a blunt trauma (96%). The observed ASA score of 3-4 was 16.8% in Germany versus 11.9% in Austria. CONCLUSION Significantly more helicopter EMS transportations (HEMS) were carried out in Austria. The authors suggest implementing international guidelines to explicitly use the HEMS system for trauma patients only a) for the rescue/care of people who have had an accident or are in life-threatening situations, b) for the transport of emergency patients with ISS > 16, c) for transportation of rescue or recovery personnel to hard to reach regions or, d) for the transport of medicinal products, especially blood products, organ transplants or medical devices.
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Affiliation(s)
- Amelie Deluca
- Institute of Tendon and Bone Regeneration, Spinal Cord Injury & Tissue Regeneration Center Salzburg, Paracelsus Medical University, Strubergasse 21, 5020, Salzburg, Österreich.
- Department of Trauma Surgery, KABEG-Klinikum Klagenfurt a.W., Klagenfurt, Österreich.
| | - Christian Deininger
- Institute of Tendon and Bone Regeneration, Spinal Cord Injury & Tissue Regeneration Center Salzburg, Paracelsus Medical University, Strubergasse 21, 5020, Salzburg, Österreich
- Department of Orthopedics and Traumatology, Salzburg University Hospital, Salzburg, Österreich
| | - Florian Wichlas
- Department of Orthopedics and Traumatology, Salzburg University Hospital, Salzburg, Österreich
| | - Andreas Traweger
- Institute of Tendon and Bone Regeneration, Spinal Cord Injury & Tissue Regeneration Center Salzburg, Paracelsus Medical University, Strubergasse 21, 5020, Salzburg, Österreich
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University Witten/Herdecke, Cologne, Deutschland
| | - Ernst J Mueller
- Department of Trauma Surgery, KABEG-Klinikum Klagenfurt a.W., Klagenfurt, Österreich
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Kaufman DA, Lopes M, Maviya N, Magder SA. The Ins and Outs of IV Fluids in Hemodynamic Resuscitation. Crit Care Med 2023; 51:1397-1406. [PMID: 37707377 DOI: 10.1097/ccm.0000000000006001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
OBJECTIVES Concise definitive review of the physiology of IV fluid (IVF) use in critically ill patients. DATA SOURCES Available literature on PubMed and MEDLINE databases. STUDY SELECTION Basic physiology studies, observational studies, clinical trials, and reviews addressing the physiology of IVF and their use in the critically ill were included. DATA EXTRACTION None. DATA SYNTHESIS We combine clinical and physiologic studies to form a framework for understanding rational and science-based use of fluids and electrolytes. CONCLUSIONS IVF administration is among the most common interventions for critically ill patients. IVF can be classified as crystalloids or colloids, and most crystalloids are sodium salts. They are frequently used to improve hemodynamics during shock states. Many recent clinical trials have sought to understand which kind of IVF might lead to better patient outcomes, especially in sepsis. Rational use of IVF rests on understanding the physiology of the shock state and what to expect IVF will act in those settings. Many questions remain unanswered, and future research should include a physiologic understanding of IVF in study design.
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Affiliation(s)
- David A Kaufman
- Division of Pulmonary and Critical Care Medicine, NYU Grossman School of Medicine, New York, NY
| | - Marcela Lopes
- Intensive Care Unit, Hospital da Cidade, Salvador, Bahia, Brazil
| | | | - Sheldon A Magder
- Department of Critical Care, McGill University Health Centre, Montréal, Québec, Canada
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Yuan J, Go LK, Ang XQT, Teo ISZ, Soh FW. Republic of Singapore Air Force Helicopter Search-and-Rescue and Medical Evacuations: A 5-Year Review. Air Med J 2022; 41:350-358. [PMID: 35750441 DOI: 10.1016/j.amj.2022.04.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 04/25/2022] [Indexed: 06/15/2023]
Abstract
The Republic of Singapore Air Force (RSAF) provides Helicopter Search-and-Rescue (SAR) and Helicopter Medical Evacuation (Heli-Medevac) coverage for the Singapore Aeronautical Search and Rescue Region (ASSR) in the South China Sea, spanning 840,000 km2. This region contains busy international shipping lanes and air traffic routes. Each year, Singapore's Helicopter SAR and Heli-Medevac service is activated multiple times to rescue personnel lost at sea or to evacuate ill and injured ship sailors or passengers to tertiary hospitals in Singapore for stabilization and advanced care. This is a retrospective review on all civilian SAR and Heli-medevac activations by the RSAF over a 5-year period from 2016 to 2020. Case profiles, presenting conditions, in-flight treatment, and patient outcomes are reviewed and discussed. Key operational observations made from RSAF's SAR and Heli-Medevac, as well as lessons learned from these missions, are discussed in this article.
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Affiliation(s)
- Jing Yuan
- Republic of Singapore Air Force, Singapore.
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Burton-Williams KM. Resuscitation of the Traumatically Injured Patient. Crit Care Nurs Clin North Am 2021; 33:245-61. [PMID: 34340788 DOI: 10.1016/j.cnc.2021.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Trauma is a leading cause of death. Optimal outcomes depend on a coordinated effort. Providers must be prepared to act in an organized and methodical manner. Recognizing and immediately treating causes of shock after trauma offer the best chance of survival to the patient. Incorporating evidence-based knowledge and resuscitation techniques learned from the military, the trauma victim experiencing acute hypovolemia has better outcomes because of advances in the clinical management of blood loss than ever before. Treatment focuses primarily on stopping the bleeding, providing damage control resuscitation, and monitoring and treating the patient for signs of shock. If the patient can be stabilized and avoid the lethal trauma triad, definitive surgical care can be achieved.
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Lott C, Truhlář A, Alfonzo A, Barelli A, González-Salvado V, Hinkelbein J, Nolan JP, Paal P, Perkins GD, Thies KC, Yeung J, Zideman DA, Soar J. [Cardiac arrest under special circumstances]. Notf Rett Med 2021; 24:447-523. [PMID: 34127910 PMCID: PMC8190767 DOI: 10.1007/s10049-021-00891-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 01/10/2023]
Abstract
These guidelines of the European Resuscitation Council (ERC) Cardiac Arrest under Special Circumstances are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required for basic and advanced life support for the prevention and treatment of cardiac arrest under special circumstances; in particular, specific causes (hypoxia, trauma, anaphylaxis, sepsis, hypo-/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), specific settings (operating room, cardiac surgery, cardiac catheterization laboratory, dialysis unit, dental clinics, transportation [in-flight, cruise ships], sport, drowning, mass casualty incidents), and specific patient groups (asthma and chronic obstructive pulmonary disease, neurological disease, morbid obesity, pregnancy).
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Affiliation(s)
- Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Mainz, Deutschland
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Tschechien
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, Charles University in Prague, Hradec Králové, Tschechien
| | - Anette Alfonzo
- Departments of Renal and Internal Medicine, Victoria Hospital, Kirkcaldy, Fife Großbritannien
| | - Alessandro Barelli
- Anaesthesiology and Intensive Care, Teaching and research Unit, Emergency Territorial Agency ARES 118, Catholic University School of Medicine, Rom, Italien
| | - Violeta González-Salvado
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Institute of Health Research of Santiago de Compostela (IDIS), Biomedical Research Networking Centres on Cardiovascular Disease (CIBER-CV), A Coruña, Spanien
| | - Jochen Hinkelbein
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Köln, Deutschland
| | - Jerry P. Nolan
- Resuscitation Medicine, Warwick Medical School, University of Warwick, CV4 7AL Coventry, Großbritannien
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, BA1 3NG Bath, Großbritannien
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Österreich
| | - Gavin D. Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, Großbritannien
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, Großbritannien
| | - Karl-Christian Thies
- Dep. of Anesthesiology and Critical Care, Bethel Evangelical Hospital, University Medical Center OLW, Bielefeld University, Bielefeld, Deutschland
| | - Joyce Yeung
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, Großbritannien
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, Großbritannien
| | | | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, Großbritannien
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Lott C, Truhlář A, Alfonzo A, Barelli A, González-Salvado V, Hinkelbein J, Nolan JP, Paal P, Perkins GD, Thies KC, Yeung J, Zideman DA, Soar J. European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances. Resuscitation 2021; 161:152-219. [PMID: 33773826 DOI: 10.1016/j.resuscitation.2021.02.011] [Citation(s) in RCA: 276] [Impact Index Per Article: 92.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
These European Resuscitation Council (ERC) Cardiac Arrest in Special Circumstances guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required to basic and advanced life support for the prevention and treatment of cardiac arrest in special circumstances; specifically special causes (hypoxia, trauma, anaphylaxis, sepsis, hypo/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), special settings (operating room, cardiac surgery, catheter laboratory, dialysis unit, dental clinics, transportation (in-flight, cruise ships), sport, drowning, mass casualty incidents), and special patient groups (asthma and COPD, neurological disease, obesity, pregnancy).
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Affiliation(s)
- Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Germany.
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Czech Republic; Department of Anaesthesiology and Intensive Care Medicine, Charles University in Prague, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Annette Alfonzo
- Departments of Renal and Internal Medicine, Victoria Hospital, Kirkcaldy, Fife, UK
| | - Alessandro Barelli
- Anaesthesiology and Intensive Care, Catholic University School of Medicine, Teaching and Research Unit, Emergency Territorial Agency ARES 118, Rome, Italy
| | - Violeta González-Salvado
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Institute of Health Research of Santiago de Compostela (IDIS), Biomedical Research Networking Centres on Cardiovascular Disease (CIBER-CV), A Coruña, Spain
| | - Jochen Hinkelbein
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Jerry P Nolan
- Resuscitation Medicine, University of Warwick, Warwick Medical School, Coventry, CV4 7AL, UK; Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, BA1 3NG, UK
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Gavin D Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Karl-Christian Thies
- Department of Anesthesiology, Critical Care and Emergency Medicine, Bethel Medical Centre, OWL University Hospitals, Bielefeld University, Germany
| | - Joyce Yeung
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, UK
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Abstract
Cardiac arrest in the operating room and in the immediate postoperative period is a potentially catastrophic event that is almost always witnessed and is frequently anticipated. Perioperative crises and perioperative cardiac arrest, although often catastrophic, are frequently managed in a timely and directed manner because practitioners have a deep knowledge of the patient's medical condition and details of recent procedures. It is hoped that the approaches described here, along with approaches for the rapid identification and management of specific high-stakes clinical scenarios, will help anesthesiologists continue to improve patient outcomes.
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Affiliation(s)
- Benjamin T Houseman
- Memorial Healthcare System Anesthesiology Residency Program, Envision Physician Services, 703 North Flamingo Road, Pembroke Pines, FL 33028, USA
| | - Joshua A Bloomstone
- Envision Physician Services, 7700 W Sunrise Boulevard, Plantation, FL 33322, USA; University of Arizona College of Medicine-Phoenix, 475 N 5th Street, Phoenix, AZ 85004, USA; Division of Surgery and Interventional Sciences, University of College London, Centre for Perioperative Medicine, Charles Bell House, 43-45 Foley Street, London, WIW 7TS, England
| | - Gerald Maccioli
- Quick'r Care, 990 Biscayne Boulevard #501, Miami, FL 33132, USA.
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Abstract
BACKGROUND Hypotensive resuscitation is an old study. But its benefits and losses are still controversial. In clinic, the method of fluid resuscitation needs more reliable experimental evidence. This study's objective is to systematically evaluate the efficacy of hypotensive resuscitation in patients with traumatic hemorrhagic shock. METHODS AND ANALYSIS Through October 2019, Web of Science, PubMed, the Cochrane Library, EMBASE, and Clinical Trials will be systematically searched to identify randomized controlled trials exploring the efficacy of hypotensive resuscitation in traumatic hemorrhagic shock. Strict screening and quality evaluation will be independently performed on the obtained literature by 2 researchers; outcome indexes will be extracted, and a meta-analysis will be performed on the data using Revman 5.3 software. ETHICS AND DISSEMINATION The stronger evidence about the efficacy of hypotensive resuscitation in traumatic hemorrhagic shock will be provided for clinicians. TRIAL REGISTRATION NUMBER PROSPERO CRD42019133169. STRENGTHS OF THIS STUDY This study is not only a simple combination of data, but also to verify and discuss the reliability of the results, and provide more convincing evidence for clinicians. LIMITATIONS OF THIS STUDY Firstly, according to the previous literature researching, it is found that the number of relevant randomized controlled trials is small and the quality level of the literature is uneven. Secondly, the efficacy of hypotensive resuscitation is discussed for a long time, different trials may take place at different times. Comparability between different trials is reduced.
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Affiliation(s)
- Hua Wang
- Department of ICU, Wujin People Hospital
| | - Mao-Bing Chen
- Department of Emergency, Wujin People Hospital Affiliated with Jiangsu University, and the Wujin Clinical College of Xuzhou Medical University, Changzhou Jiangsu, PR China
| | - Xu-Wen Zheng
- Department of Emergency, Wujin People Hospital Affiliated with Jiangsu University, and the Wujin Clinical College of Xuzhou Medical University, Changzhou Jiangsu, PR China
| | - Qi-Han Zheng
- Department of Emergency, Wujin People Hospital Affiliated with Jiangsu University, and the Wujin Clinical College of Xuzhou Medical University, Changzhou Jiangsu, PR China
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Wearmouth C, Smith J. Development of a nurse-led tranexamic acid administration protocol for trauma patients in rural South Africa. Afr J Emerg Med 2019; 9:S52-5. [PMID: 30976502 DOI: 10.1016/j.afjem.2018.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 10/03/2018] [Indexed: 11/24/2022] Open
Abstract
Introduction Administration of tranexamic acid (TXA) has been shown to effectively reduce all-cause mortality in trauma patients when given within three hours of injury. We found that many trauma patients in our hospital were not receiving TXA. This was due to a variety of factors, including late presentation to hospital, lack of staff awareness, short staffing, and unavailable drugs or equipment. Our aim was to develop a protocol for safe, nurse-led administration of TXA in the emergency centre in order to increase the number of eligible patients treated. Methods We developed a protocol based on the inclusion criteria of the CRASH-2 study, opting to use physiological observations along with criteria from the South African Triage Scale to allow nursing staff to identify patients with, or at risk of, significant haemorrhage. We tailored the protocol to the equipment and training available in our poorly resourced rural healthcare setting. Results In a two-month period, 14 patients were given TXA by nurses before the arrival of a doctor. 13/14 (92.9%) were deemed appropriate, with 1/14 (7.1%) deemed inappropriate due to the time since injury. 12/13 (92.3%) patients received the correct infusion dose, with 1/13 (7.7%) only receiving the infusion once the doctor arrived. No adverse events were reported. Conclusions Nursing staff in resource poor rural settings can use a protocol based on the South African Triage Scale and the CRASH-2 study to safely administer TXA to trauma patients. We believe this to be the first published literature on nurse-led administration of TXA. Mortality from trauma may be reduced in rural settings by the timely administration of TXA in the prehospital and rural primary healthcare settings.
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Abstract
Over the last decade, trends in fluid resuscitation have changed dramatically as have our practices. Research is driving trauma centers across the globe to initiate modifications in fluid resuscitation of the hemorrhagic trauma patients both in the prehospital and intrahospital arena. This is being done by combining the theory of permissive hypotension and damage control surgery with hemostatic resuscitation as the preferred methods of resuscitation in patients with hemorrhagic shock. The literature illustrates that previous strategies we considered to be beneficial are actually detrimental to the outcomes of these severely injured patients. This complex and continuously changing adaptation in practice must be made without losing our strategic focus of improvement of outcomes and recognition of the morbidity associated with bleeding of the trauma patient. Designating limits on large-volume crystalloid resuscitation will prevent cellular injury. These wiser resuscitation strategies are key in the efforts to reduce mortality and to improve outcomes. This article is to serve as a review of each of the resuscitative fluid strategies as well as new methods of trauma resuscitation.
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Skinner DL, Kong VY, de Vasconcellos K, Bruce JL, Bekker W, Laing GL, Clarke DL. Acute Kidney Injury on Presentation to a Major Trauma Service is Associated with Poor Outcomes. J Surg Res 2018; 232:376-382. [DOI: 10.1016/j.jss.2018.06.069] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 05/18/2018] [Accepted: 06/20/2018] [Indexed: 10/28/2022]
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Prentice C, Jeyanathan J, De Coverly R, Williams J, Lyon R. Emergency medical dispatch recognition, clinical intervention and outcome of patients in traumatic cardiac arrest from major trauma: an observational study. BMJ Open 2018; 8:e022464. [PMID: 30185576 PMCID: PMC6129099 DOI: 10.1136/bmjopen-2018-022464] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVES The aim of this study is to describe the demographics of reported traumatic cardiac arrest (TCA) victims, prehospital resuscitation and survival to hospital rate. SETTING Helicopter Emergency Medical Service (HEMS) in south-east England, covering a resident population of 4.5 million and a transient population of up to 8 million people. PARTICIPANTS Patients reported on the initial 999 call to be in suspected traumatic cardiac arrest between 1 July 2016 and 31 December 2016 within the trust's geographical region were identified. The inclusion criteria were all cases of reported TCA on receipt of the initial emergency call. Patients were subsequently excluded if a medical cause of cardiac arrest was suspected. OUTCOME MEASURES Patient records were analysed for actual presence of cardiac arrest, prehospital resuscitation procedures undertaken and for survival to hospital rates. RESULTS 112 patients were reported to be in TCA on receipt of the 999/112 call. 51 (46%) were found not to be in TCA on arrival of emergency medical services. Of the 'not in TCA cohort', 34 (67%) received at least one advanced prehospital medical intervention (defined as emergency anaesthesia, thoracostomy, blood product transfusion or resuscitative thoracotomy). Of the 61 patients in actual TCA, 10 (16%) achieved return-of-spontaneous circulation. In 45 (88%) patients, the HEMS team escorted the patient to hospital. CONCLUSION A significant proportion of patients reported to be in TCA on receipt of the emergency call are not in actual cardiac arrest but are critically unwell requiring advanced prehospital medical intervention. Early activation of an enhanced care team to a reported TCA call allows appropriate advanced resuscitation. Further research is warranted to determine which interventions contribute to improved TCA survival.
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Affiliation(s)
- Craig Prentice
- Kent, Surrey and Sussex Air Ambulance Trust, Redhill, UK
| | - Jeyasankar Jeyanathan
- Kent, Surrey and Sussex Air Ambulance Trust, Redhill, UK
- Academic Department of Military Anaesthesia and Critical Care, Defence Medical Services, Birmingham, UK
| | | | - Julia Williams
- Kent, Surrey and Sussex Air Ambulance Trust, Redhill, UK
- University of Hertfordshire, Hertfordshire, UK
- South East Coast Ambulance Service, Crawley, UK
| | - Richard Lyon
- Kent, Surrey and Sussex Air Ambulance Trust, Redhill, UK
- University of Surrey, Guildford, UK
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Self WH, Semler MW, Bellomo R, Brown SM, deBoisblanc BP, Exline MC, Ginde AA, Grissom CK, Janz DR, Jones AE, Liu KD, Macdonald SPJ, Miller CD, Park PK, Reineck LA, Rice TW, Steingrub JS, Talmor D, Yealy DM, Douglas IS, Shapiro NI. Liberal Versus Restrictive Intravenous Fluid Therapy for Early Septic Shock: Rationale for a Randomized Trial. Ann Emerg Med 2018; 72:457-466. [PMID: 29753517 DOI: 10.1016/j.annemergmed.2018.03.039] [Citation(s) in RCA: 106] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 03/25/2018] [Accepted: 03/26/2018] [Indexed: 12/29/2022]
Abstract
Prompt intravenous fluid therapy is a fundamental treatment for patients with septic shock. However, the optimal approach for administering intravenous fluid in septic shock resuscitation is unknown. Two competing strategies are emerging: a liberal fluids approach, consisting of a larger volume of initial fluid (50 to 75 mL/kg [4 to 6 L in an 80-kg adult] during the first 6 hours) and later use of vasopressors, versus a restrictive fluids approach, consisting of a smaller volume of initial fluid (≤30 mL/kg [≤2 to 3 L]), with earlier reliance on vasopressor infusions to maintain blood pressure and perfusion. Early fluid therapy may enhance or maintain tissue perfusion by increasing venous return and cardiac output. However, fluid administration may also have deleterious effects by causing edema within vital organs, leading to organ dysfunction and impairment of oxygen delivery. Conversely, a restrictive fluids approach primarily relies on vasopressors to reverse hypotension and maintain perfusion while limiting the administration of fluid. Both strategies have some evidence to support their use but lack robust data to confirm the benefit of one strategy over the other, creating clinical and scientific equipoise. As part of the National Heart, Lung, and Blood Institute Prevention and Early Treatment of Acute Lung Injury Network, we designed a randomized clinical trial to compare the liberal and restrictive fluids strategies, the Crystalloid Liberal or Vasopressor Early Resuscitation in Sepsis trial. The purpose of this article is to review the current literature on approaches to early fluid resuscitation in adults with septic shock and outline the rationale for the upcoming trial.
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Affiliation(s)
- Wesley H Self
- Vanderbilt University Medical Center, Nashville, TN.
| | | | - Rinaldo Bellomo
- University of Melbourne School of Medicine, Victoria, Australia
| | - Samuel M Brown
- Intermountain Medical Center and University of Utah, Murray, UT
| | | | | | - Adit A Ginde
- University of Colorado School of Medicine, Aurora, CO
| | - Colin K Grissom
- Intermountain Medical Center and University of Utah, Murray, UT
| | - David R Janz
- Louisiana State University Health Sciences Center, New Orleans, LA
| | - Alan E Jones
- University of Mississippi Medical Center, Jackson, MS
| | - Kathleen D Liu
- University of California San Francisco Medical Center, San Francisco, CA
| | | | | | | | - Lora A Reineck
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Todd W Rice
- Vanderbilt University Medical Center, Nashville, TN
| | - Jay S Steingrub
- University of Massachusetts Medical School-Baystate, Springfield, MA
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McEvoy MD, Thies KC, Einav S, Ruetzler K, Moitra VK, Nunnally ME, Banerjee A, Weinberg G, Gabrielli A, Maccioli GA, Dobson G, O’Connor MF. Cardiac Arrest in the Operating Room. Anesth Analg 2018; 126:889-903. [DOI: 10.1213/ane.0000000000002595] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Mohamed WRA, Leach MJ, Reda NA, Abd-Ellatif MM, Mohammed MA, Abd-Elaziz MA. The effectiveness of clinical pathway-directed care on hospitalisation-related outcomes in patients with severe traumatic brain injury: A quasi-experimental study. J Clin Nurs 2018; 27:e820-e832. [PMID: 29193516 DOI: 10.1111/jocn.14194] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2017] [Indexed: 12/14/2022]
Abstract
AIMS AND OBJECTIVES To compare the effectiveness of clinical pathway-directed care to usual care on hospitalisation-related outcomes in patients with severe traumatic brain injury (STBI). BACKGROUND Severe traumatic brain injury is a major cause of disability and mortality in young adults. Clinical pathways endeavour to bring evidence and clinical practice closer together to foster the delivery of best practice and to improve patient outcomes. DESIGN Quasi-experimental study. METHODS The study was conducted in a trauma intensive care unit of a large teaching hospital in Egypt. Patients aged 18-60 years with a diagnosis of STBI, a Glasgow Coma Scale score between 3-8 and a nonpenetrating head injury were consecutively assigned to 15 days of care. The outcomes assessed were complications related to hospitalisation, clinical variances, length of intensive care unit (ICU) stay, ICU readmission rate and patient/family satisfaction. RESULTS Sixty participants completed the study (30 in each arm). Apart from age, there were no significant differences between groups in baseline characteristics. The clinical pathway group demonstrated statistically significantly fewer cases of hospitalisation-related complications on day 15, and a significantly shorter length of ICU stay, lower ICU readmission rate and a high level of patient/family satisfaction when compared with the usual care group. The effect of the intervention on fever, pressure ulceration, hyperglycaemia and readmission to the ICU was no longer statistically significant after controlling for age. CONCLUSIONS The findings of the current study suggest that the implementation of a clinical pathway for patients with severe TBI may be helpful in improving the patient experience as well as some hospitalisation-related outcomes. RELEVANCE TO CLINICAL PRACTICE The provision of clinical pathway-directed care in a trauma ICU may offer benefits to the patient, family and institution beyond that provided by usual care.
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Affiliation(s)
| | - Matthew J Leach
- Department of Rural Health, University of South Australia, Adelaide, SA, Australia
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Lai YC, Wu CH, Chen HW, Wang LJ, Wong YC. Predictors of active arterial hemorrhage on angiography in pelvic fracture patients. Jpn J Radiol 2017; 36:223-230. [PMID: 29282615 DOI: 10.1007/s11604-017-0716-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 12/17/2017] [Indexed: 01/02/2023]
Abstract
PURPOSE To determine predictors of active angiographic hemorrhage in pelvic fracture patients. MATERIALS AND METHODS This retrospective study included 66 trauma patients who had major hemorrhages due to pelvic fractures, and who underwent pelvic angiography between January 2012 and December 2014. The study population comprised 31 males and 35 females (mean age 44.2 ± 20.7 years). The main outcome was active hemorrhage on pelvic angiography. Clinical and imaging variables including demographics, hemodynamic parameters, injury severity, types of pelvic fracture, laboratory data, blood transfusions and CT findings were analyzed. Multivariate logistic regression was used to identify predictors of active angiographic hemorrhage. RESULTS Of the 66 study patients included, 41 patients had active angiographic hemorrhage. These patients had more blood transfusions, higher activated partial thromboplastin times and higher rates of contrast extravasation on CT (p < 0.05). Three independent predictors of active angiographic hemorrhage were identified, including contrast extravasation on CT (OR: 74.6, p < 0.001), more than 8 units of RBC transfusions (OR: 12.5, p = 0.018) and ISS ≥ 16 (OR: 11.1, p = 0.029). CONCLUSION Contrast extravasation on CT, high volume RBC transfusions and ISS ≥ 16 can help us to select pelvic fracture patients for angiography more precisely.
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Affiliation(s)
- Ying-Chieh Lai
- Division of Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Gueishan, Taoyuan, 333, Taiwan
| | - Cheng-Hsien Wu
- Division of Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Gueishan, Taoyuan, 333, Taiwan
| | - Huan-Wu Chen
- Division of Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Gueishan, Taoyuan, 333, Taiwan
| | - Li-Jen Wang
- Division of Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Gueishan, Taoyuan, 333, Taiwan
| | - Yon-Cheong Wong
- Division of Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Gueishan, Taoyuan, 333, Taiwan.
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18
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Affiliation(s)
- D G Nevin
- Department of Anaesthesia and London's Air Ambulance, The Royal London Hospital Major Trauma Centre, Bart's Health NHS Trust, London, UK
| | - K Brohi
- Centre for Trauma Sciences, The Blizard Institute, Queen Mary University of London, London, UK
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Libert N, Harrois A, Baudry N, Vicaut E, Duranteau J. Intestinal microcirculation and mucosal oxygenation during hemorrhagic shock and resuscitation at different inspired oxygen concentrations. J Trauma Acute Care Surg 2017; 83:476-84. [PMID: 28538634 DOI: 10.1097/TA.0000000000001573] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Hypotensive resuscitation is the standard of care of hemorrhagic shock resuscitation. The optimal level of arterial pressure is debated and there is a lack of data on relationships between arterial pressure, microcirculation and tissue oxygenation. We investigated the relationship between mean arterial pressure, intestinal microcirculation and mucosal oxygen tension during hemorrhagic shock and resuscitation at different inspired oxygen fraction concentration. METHODS The study was divided into two phases: 32 mice were progressively exsanguinated and then transfused in mean arterial pressure (MAP)-titrated steps of 10 mm Hg. Mice were randomized to four experimental groups: a control group in which sham mice underwent a laparotomy and three interventional groups with a common phase of exsanguination followed by progressive resuscitation at three different inspired oxygen concentrations (FIO2) (15%, 30%, and 100%). Intestinal mucosal oxygenation (intestinal PO2) and microcirculatory parameters were recorded at each 10 mm Hg MAP step. RESULTS During exsanguination, intestinal PO2 decreased linearly with MAP levels. Microcirculatory parameters decreased nonlinearly with MAP levels while they had a linear relationship with intestinal PO2. Intestinal mucosal hypoxia (PO2 ≤ 20 mm Hg) began at a MAP of 60 mm Hg and MAP < 60 mm Hg was associated with a high percentage of animal with intestinal hypoxia (≥32%). Combination of MAP and microcirculatory parameters was superior to MAP alone at predicting mucosal oxygenation. Inversely, during resuscitation with FIO2 = 30%, the microcirculatory parameters increased linearly with MAP levels while they had a nonlinear relationship with intestinal PO2. Hypoxia (FIO2 = 15%) was poorly tolerated. In hyperoxic group (FIO2 = 100%) intestinal PO2 became significantly higher than baseline values as soon as 50 mm Hg MAP. CONCLUSION During hemorrhagic shock, intestinal PO2 decreased linearly with MAP levels and microcirculatory parameters. Associating MAP and microcirculatory parameters allowed a better prediction of intestinal PO2 than MAP alone. A MAP < 60 mm Hg was associated with a high percentage of animal with intestinal hypoxia. Normoxic resuscitation (FIO2 = 30%) was sufficient to restore intestinal PO2.
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Lawrence MJ, Marsden N, Kaczynski J, Davies G, Davies N, Hawkins K, Perumal S, Brown MR, Morris K, Davidson SJ, Williams PR, Evans PA. An Investigation Into the Effects of In Vitro Dilution With Different Colloid Resuscitation Fluids on Clot Microstructure Formation. Anesth Analg 2017; 123:1081-1088. [PMID: 27636739 DOI: 10.1213/ane.0000000000001536] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Balancing the beneficial effects of resuscitation fluids against their detrimental effect on hemostasis is an important clinical issue. We aim to compare the in vitro effects of 3 different colloid resuscitation fluids (4.5% albumin, hydroxyethyl starch [Voluven 6%], and gelatin [Geloplasma]) on clot microstructure formation using a novel viscoelastic technique, the gel point. This novel hemorheologic technique measures the biophysical properties of the clot and provides an assessment of clot microstructure from its viscoelastic properties. Importantly, in contrast to many assays in routine clinical use, the measurement is performed using unadulterated whole blood in a near-patient setting and provides rapid assessment of coagulation. We hypothesized that different colloids will have a lesser or greater detrimental effect on clot microstructure formation when compared against each other. METHODS Healthy volunteers were recruited into the study (n = 104), and a 20-mL sample of whole blood was obtained. Each volunteer was assigned to 1 of the 3 fluids, and the sample was diluted to 1 of 5 different dilutions (baseline, 10%, 20%, 40%, and 60%). The blood was tested using the gel point technique, which measures clot mechanical strength and quantifies clot microstructure (df) at the incipient stages of fibrin formation. RESULTS df and clot mechanical strength decrease with progressive dilution for all 3 fluids. A significant reduction in df from baseline was recorded at dilutions of 20% for albumin (P < .0001), 40% for starch (P < .0001), and 60% for gelatin (P < .0001). We also observed significant differences, in terms of df, when comparing the different types of colloid (P < .0001). We found that albumin dilution produced the largest changes in clot microstructure, providing the lowest values of df (= 1.41 ± 0.061 at 60% dilution) compared with starch (1.52 ± 0.081) and gelatin (1.58 ± 0.063). CONCLUSIONS We show that dilution with all 3 fluids has a significant effect on coagulation at even relatively low dilution volumes (20% and 40%). Furthermore, we quantify, using a novel viscoelastic technique, how the physiochemical properties of the 3 colloids exert individual changes on clot microstructure.
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Affiliation(s)
- Matthew James Lawrence
- From the *NISCHR Haemostasis Biomedical Research Unit, Morriston Hospital, Abertawe Bro Morgannwg University Health Board, Swansea, United Kingdom; †NISCHR Biomedical Research Unit, Medical School, Swansea University, Swansea, United Kingdom; ‡The Welsh Centre for Burns and Plastic Surgery, Abertawe Bro Morgannwg University Health Board, Morriston Hospital, Swansea, United Kingdom; §Department of Surgery, Morriston Hospital, Abertawe Bro Morgannwg University Health Board, Swansea University, Swansea, United Kingdom; ∥Emergency Department, Morriston Hospital, Abertawe Bro Morgannwg University Health Board, Swansea, United Kingdom; ¶Centre of Complex Fluids, College of Engineering, Swansea University, Swansea, United Kingdom; #School of Applied Science, University of Wales Institute Cardiff, Cardiff, United Kingdom; and **Department of Haematology, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
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Baxter J, Cranfield KR, Clark G, Harris T, Bloom B, Gray AJ. Do lactate levels in the emergency department predict outcome in adult trauma patients? A systematic review. J Trauma Acute Care Surg 2016; 81:555-66. [DOI: 10.1097/ta.0000000000001156] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Wilson MH. Monro-Kellie 2.0: The dynamic vascular and venous pathophysiological components of intracranial pressure. J Cereb Blood Flow Metab 2016; 36:1338-50. [PMID: 27174995 PMCID: PMC4971608 DOI: 10.1177/0271678x16648711] [Citation(s) in RCA: 168] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 04/05/2016] [Accepted: 04/17/2016] [Indexed: 12/16/2022]
Abstract
For 200 years, the 'closed box' analogy of intracranial pressure (ICP) has underpinned neurosurgery and neuro-critical care. Cushing conceptualised the Monro-Kellie doctrine stating that a change in blood, brain or CSF volume resulted in reciprocal changes in one or both of the other two. When not possible, attempts to increase a volume further increase ICP. On this doctrine's "truth or relative untruth" depends many of the critical procedures in the surgery of the central nervous system. However, each volume component may not deserve the equal weighting this static concept implies. The slow production of CSF (0.35 ml/min) is dwarfed by the dynamic blood in and outflow (∼700 ml/min). Neuro-critical care practice focusing on arterial and ICP regulation has been questioned. Failure of venous efferent flow to precisely match arterial afferent flow will yield immediate and dramatic changes in intracranial blood volume and pressure. Interpreting ICP without interrogating its core drivers may be misleading. Multiple clinical conditions and the cerebral effects of altitude and microgravity relate to imbalances in this dynamic rather than ICP per se. This article reviews the Monro-Kellie doctrine, categorises venous outflow limitation conditions, relates physiological mechanisms to clinical conditions and suggests specific management options.
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Affiliation(s)
- Mark H Wilson
- Institute of Pre-Hospital Care, London's Air Ambulance, The Royal London Hospital, Queen Mary College, London, UK
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Bihari S, Teubner DJ, Prakash S, Beatty T, Morphett M, Bellomo R, Bersten A. Fluid bolus therapy in emergency department patients: Indications and physiological changes. Emerg Med Australas 2016; 28:531-7. [PMID: 27374939 DOI: 10.1111/1742-6723.12621] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Revised: 05/05/2016] [Accepted: 05/14/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The aim of the present paper is to study the indications for fluid bolus therapy (FBT) and its associated physiological changes in ED patients. METHODS Prospective observational study of FBT in a tertiary ED, we recorded indications, number, types and volumes, resuscitation goals and perceived success rates of FBT. Moreover, we studied key physiological variables before, 10 min, 1 h and 2 h after FBT. RESULTS We studied 500 FBT episodes (750 [500-1250] mL). Median age was 59 (36-76) years and 57% were male. Shock was deemed present in 135 (27%) patients, septic shock in 80 (16%), and cardiogenic shock in 30 (6%). Overall, 0.9% saline (84%) was the most common fluid and hypotension the most common indication (70%). 'Avoidance of hospital/ICU admission' was the goal perceived to have the greatest success rate (85%). However, although mean arterial pressure (MAP) increased (P < 0.01) and heart rate (HR) decreased (P = 0.04) at 10 min (P = 0.01), both returned to baseline at 1 and 2 h. In contrast, respiratory rate (RR) increased at 1 (P < 0.01) and 2 h (P = 0.03) and temperature decreased at 1 and 2 h (both P < 0.001). In patients with shock, 1 h after FBT, there was a median 3 mmHg increase in MAP (P = 0.01) but no change in HR (P = 0.44), while RR increased (P < 0.01) and temperature decreased (P = 0.01). CONCLUSIONS In ED, FBT is used mostly in patients without shock. However, after an immediate haemodynamic effect, FBT is associated with absent or limited physiological changes at 1 or 2 h. Even in shocked patients, the changes in MAP at 1 or 2 h after FBT are small.
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Affiliation(s)
- Shailesh Bihari
- Intensive and Critical Care Unit, Flinders Medical Centre, Adelaide, South Australia, Australia. , .,Department of Critical Care Medicine, Flinders University, Adelaide, South Australia, Australia. ,
| | - David J Teubner
- Department of Critical Care Medicine, Flinders University, Adelaide, South Australia, Australia.,Department of Emergency Medicine, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Shivesh Prakash
- Intensive and Critical Care Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Thomas Beatty
- Department of Emergency Medicine, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Mark Morphett
- Department of Emergency Medicine, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, The University of Melbourne, Austin Hospital, Melbourne, Victoria, Australia.,The University of Melbourne, Melbourne, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia
| | - Andrew Bersten
- Intensive and Critical Care Unit, Flinders Medical Centre, Adelaide, South Australia, Australia.,Department of Critical Care Medicine, Flinders University, Adelaide, South Australia, Australia
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Lai WH, Wu SC, Rau CS, Kuo PJ, Hsu SY, Chen YC, Hsieh HY, Hsieh CH. Systolic Blood Pressure Lower than Heart Rate upon Arrival at and Departure from the Emergency Department Indicates a Poor Outcome for Adult Trauma Patients. Int J Environ Res Public Health 2016; 13:ijerph13060528. [PMID: 27231926 PMCID: PMC4923985 DOI: 10.3390/ijerph13060528] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 05/13/2016] [Accepted: 05/19/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Hemorrhage is a leading cause of preventable trauma death. In this study, we used the reverse shock index (RSI), a ratio of systolic blood pressure (SBP) to heart rate (HR), to evaluate the hemodynamic stability of trauma patients. As an SBP lower than the HR (RSI < 1) may indicate hemodynamic instability, the objective of this study was to assess the associated complications in trauma patients with an RSI < 1 upon arrival at the emergency department (ED) (indicated as (A)RSI) and at the time of departure from the ED (indicated as (L)RSI) to the operative room or for admission. METHODS Data obtained from all 16,548 hospitalized patients recorded in the trauma registry system at a Level I trauma center between January 2009 and December 2013 were retrospectively reviewed. A total of 10,234 adult trauma patients aged ≥20 were enrolled and subsequently divided into four groups: Group I, (A)RSI ≥ 1 and (L)RSI ≥ 1 (n = 9827); Group II, (A)RSI ≥ 1 and (L)RSI < 1 (n = 76); Group III, (A)RSI < 1 and (L)RSI ≥ 1 (n = 251); and Group IV, (A)RSI < 1 and (L)RSI < 1 (n = 80). Pearson's χ² test, Fisher's exact test, or independent Student's t-test was conducted to compare trauma patients in Groups II, III, and IV with those in Group I. RESULTS Patients in Groups II, III, and IV had a higher injury severity score and underwent a higher number of procedures, including intubation, chest tube insertion, and blood transfusion, than Group I patients. Additionally, patients of these groups had increased hospital length of stay (16.3 days, 14.9 days, and 22.0 days, respectively), proportion of patients admitted to the intensive care unit (ICU) (48.7%, 43.0%, and 62.5%, respectively), and in-hospital mortality (19.7%, 7.6%, and 27.5%, respectively). Although the trauma patients who had a SBP < 90 mmHg either upon arrival at or departure from the ED also present a more severe injury and poor outcome, those patients who had a SBP ≥ 90 mmHg but an RSI < 1 had a more severe injury and poor outcome than those patients who had a SBP ≥ 90 mmHg and an RSI ≥ 1. CONCLUSIONS SBP lower than heart rate (RSI < 1) either upon arrival at or departure from the ED may indicate a detrimental sign of poor outcome in adult trauma patients even in the absence of noted hypotension.
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Affiliation(s)
- Wei-Hung Lai
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung City 833, Taiwan.
| | - Shao-Chun Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung City 833, Taiwan.
| | - Cheng-Shyuan Rau
- Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No.123, Ta-Pei Road, Niao-Song District, Kaohsiung City 833, Taiwan.
| | - Pao-Jen Kuo
- Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung City 833, Taiwan.
| | - Shiun-Yuan Hsu
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung City 833, Taiwan.
| | - Yi-Chun Chen
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung City 833, Taiwan.
| | - Hsiao-Yun Hsieh
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung City 833, Taiwan.
| | - Ching-Hua Hsieh
- Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No.123, Ta-Pei Road, Niao-Song District, Kaohsiung City 833, Taiwan.
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Abstract
Polytrauma associated with traumatic brain injury (TBI) is defined as a concurrent injury to the brain and one or more body areas or organ systems that results in physical, cognitive, and psychosocial impairments. Consequently, polytrauma accompanied by TBI presents a unique challenge for emergency medicine, in particular, to those associated with the austere environments encountered in military theaters of operation and the logistics of en-route care. Here, we attempt to put needed focus on this medical emergency, specifically addressing the problem of an exsanguinating polytrauma requiring fluid resuscitation complicated by TBI. Critical questions to consider are the following: (1) What is the optimal resuscitation fluid for these patients? (2) In defining the resuscitation fluid, what considerations must be given with regard to the very specific logistics of military operations? and (3) Can treatment of the brain injury be initiated in parallel with resuscitation practices. Recognizing the immense clinical and experimental complexity of this problem, our goal was to encourage research that embraces with high-fidelity 'combined' animal models of polytrauma and TBI with an objective toward elucidating safe and effective neurotherapeutic resuscitation protocols.
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Jones AW. Impact of Trauma, Massive Blood Loss and Administration of Resuscitation Fluids on a Person's Blood-Alcohol Concentration and Rate of Ethanol Metabolism. Acad Forensic Pathol 2016; 6:77-88. [PMID: 31239874 DOI: 10.23907/2016.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 10/30/2015] [Accepted: 12/05/2015] [Indexed: 11/12/2022]
Abstract
Excessive drinking and drunkenness are tightly linked to many types of intentional and unintentional injuries involving trauma and blood loss, which often necessitate emergency medical intervention. This article considers the impact of trauma, massive blood loss, and the administration of life-saving replacement fluids on a person's blood alcohol concentration (BAC) and rate of ethanol metabolism. Both German and English language journals were reviewed and results from animal experiments, human studies, and actual victims of trauma undergoing life-saving treatment were considered. If trauma-related bleeding occurs when some ingested alcohol remains unabsorbed in the stomach, then under these circumstances continued absorption into portal venous blood is delayed, owing to altered splanchnic circulation. Hemodilution caused by administration of replacement fluids has only minimal effects on a preexisting BAC, because ethanol distributes into the total body water (TBW) compartment, which represents 50-60% of body weight. After hypovolemia there is a transfer of fluids from tissue compartments into the blood, which becomes more like plasma in composition with lower hematocrit and hemoglobin content. Unless the trauma or emergency treatment impedes hepatic blood flow, the rate of ethanol metabolism is not expected to differ from normal values, namely 0.10-0.25 g/L/h (0.01-0.025 g% per h). If ethanol is fully absorbed and distributed in all body fluids and tissues, neither massive blood loss nor administration of resuscitating fluids is expected to have any significant effect on a preexisting BAC or the rate of ethanol metabolism.
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Affiliation(s)
- Alan W Jones
- Department of Clinical Pharmacology, Faculty of Medicine, University of Linköping, Sweden
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Battle CE, Lecky FE, Stacey T, Edwards A, Evans PA. Management of the anticoagulated trauma patient in the emergency department: a survey of current practice in England and Wales. Emerg Med J 2016; 33:403-7. [PMID: 26727974 DOI: 10.1136/emermed-2015-205120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 12/13/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVE The aim of this study was to investigate current management of the anticoagulated trauma patient in the emergency departments (EDs) in England and Wales. METHODS A survey exploring management strategies for anticoagulated trauma patients presenting to the ED was developed with two patient scenarios concerning assessment of coagulation status, reversal of international normalised ratio (INR), management of hypotension and management strategies for each patient. Numerical data are presented as percentages of total respondents to that particular question. RESULTS 106 respondents from 166 hospitals replied to the survey, with 24% of respondents working in a major trauma unit with a specialist neurosurgical unit. Variation was reported in the assessment and management strategies of the elderly anticoagulated poly-trauma patient described in scenario one. Variation was also evident in the responses between the neurosurgical and non-neurosurgical units for the head-injured, anticoagulated trauma patient in scenario two. CONCLUSION The results of this study highlight the similarities and variation in the management strategies used in the EDs in England and Wales for the elderly, anticoagulated trauma patient. The variations in practice reported may be due to the differences evident in the available guidelines for these patients.
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Affiliation(s)
- Ceri E Battle
- NISCHR Haemostasis Biomedical Research Unit Epidemiology Division, Morriston Hospital, Swansea, UK
| | - Fiona E Lecky
- The Trauma Audit and Research Network, University of Manchester, University of Sheffield/University of Manchester/Salford Royal Hospital NHS Foundation Trust. Emergency Medicine Research in Sheffield (EMRiS), Health Services Research, School of Health and Related Research, Sheffield, UK
| | - Tom Stacey
- The Trauma Audit and Research Network, University of Manchester, Salford, UK
| | - Antoinette Edwards
- The Trauma Audit and Research Network, University of Manchester, Salford, UK
| | - Phillip A Evans
- NISCHR Haemostasis Biomedical Research Unit, Morriston Hospital, Swansea, UK
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Truhlář A, Deakin C, Soar J, Khalifa G, Alfonzo A, Bierens J, Brattebø G, Brugger H, Dunning J, Hunyadi-antičević S, Koster R, Lockey D, Lott C, Paal P, Perkins G, Sandroni C, Thies K, Zideman D, Nolan J. Kreislaufstillstand in besonderen Situationen: Kapitel 4 der Leitlinien zur Reanimation 2015 des European Resuscitation Council. Notf Rett Med 2015; 18:833-903. [DOI: 10.1007/s10049-015-0096-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Truhlář A, Deakin CD, Soar J, Khalifa GEA, Alfonzo A, Bierens JJLM, Brattebø G, Brugger H, Dunning J, Hunyadi-Antičević S, Koster RW, Lockey DJ, Lott C, Paal P, Perkins GD, Sandroni C, Thies KC, Zideman DA, Nolan JP, Böttiger BW, Georgiou M, Handley AJ, Lindner T, Midwinter MJ, Monsieurs KG, Wetsch WA. European Resuscitation Council Guidelines for Resuscitation 2015: Section 4. Cardiac arrest in special circumstances. Resuscitation 2015; 95:148-201. [PMID: 26477412 DOI: 10.1016/j.resuscitation.2015.07.017] [Citation(s) in RCA: 525] [Impact Index Per Article: 58.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Czech Republic; Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, Hradec Králové, Czech Republic.
| | - Charles D Deakin
- Cardiac Anaesthesia and Cardiac Intensive Care, NIHR Southampton Respiratory Biomedical Research Unit, Southampton University Hospital NHS Trust, Southampton, UK
| | - Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | | | - Annette Alfonzo
- Departments of Renal and Internal Medicine, Victoria Hospital, Kirkcaldy, Fife, UK
| | | | - Guttorm Brattebø
- Bergen Emergency Medical Services, Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Hermann Brugger
- EURAC Institute of Mountain Emergency Medicine, Bozen, Italy
| | - Joel Dunning
- Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK
| | | | - Rudolph W Koster
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | - David J Lockey
- Intensive Care Medicine and Anaesthesia, Southmead Hospital, North Bristol NHS Trust, Bristol, UK; School of Clinical Sciences, University of Bristol, UK
| | - Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-Universitaet, Mainz, Germany
| | - Peter Paal
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, Queen Mary University of London, London, UK; Department of Anaesthesiology and Critical Care Medicine, University Hospital Innsbruck, Austria
| | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK; Critical Care Unit, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Claudio Sandroni
- Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy
| | | | - David A Zideman
- Department of Anaesthetics, Imperial College Healthcare NHS Trust, London, UK
| | - Jerry P Nolan
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK; School of Clinical Sciences, University of Bristol, UK
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Yang G, Hu Y, Peng X, Zhu Y, Zang J, Li T, Liu L. Hypotensive resuscitation in combination with arginine vasopressin may prolong the hypotensive resuscitation time in uncontrolled hemorrhagic shock rats. J Trauma Acute Care Surg 2015; 78:760-6. [PMID: 25742254 DOI: 10.1097/TA.0000000000000564] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The optimal resuscitation strategy for traumatic hemorrhagic shock is not completely determined. The objective of the present study was to investigate whether hypotensive resuscitation in combination with arginine vasopressin (AVP) can prolong the hypotensive resuscitation time by minimizing blood loss and stabilizing hemodynamics for uncontrolled hemorrhagic shock. METHODS With an established rat model of uncontrolled hemorrhagic shock, we compared the beneficial effects of hypotensive resuscitation in combination with AVP to maintain blood pressure at 50 mm Hg for 3 hours to hypotensive resuscitation alone on animal survival, blood loss, and vital organ functions. RESULTS Hypotensive resuscitation in combination with AVP maintenance for 3 hours significantly reduced total blood loss and fluid requirement during hypotensive resuscitation period and significantly improved the survival of shock rats as compared with hypotensive resuscitation alone. Among the four concentrations of AVP, 5 × 10 U/mL had the best effect: it significantly improved hemodynamics and increased cardiac function, oxygen delivery, as well as hepatic blood flow and hepatic function in the shock rats. However, renal blood flow in the hypotensive resuscitation + AVP group was lower than that in the hypotensive resuscitation alone group. CONCLUSION Hypotensive resuscitation in combination with early application of AVP could prolong the tolerance time of hypotensive resuscitation and "buy" longer safe prehospital transport time by reducing blood loss and stabilizing hemodynamics. This strategy may be a promising strategy for the early management of trauma patients with active bleeding.
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Brinck T, Handolin L, Lefering R. The Effect of Evolving Fluid Resuscitation on the Outcome of Severely Injured Patients: An 8-year Experience at a Tertiary Trauma Center. Scand J Surg 2015; 105:109-16. [PMID: 25989810 DOI: 10.1177/1457496915586650] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2014] [Accepted: 04/04/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND AIMS Fluid resuscitation of severely injured patients has shifted over the last decade toward less crystalloids and more blood products. Helsinki University trauma center implemented the massive transfusion protocol in the end of 2009. The aim of the study was to review the changes in fluid resuscitation and its influence on outcome of severely injured patients with hemodynamic compromise treated at the single tertiary trauma center. MATERIAL AND METHODS Data on severely injured patients (New Injury Severity Score > 15) from Helsinki University Hospital trauma center's trauma registry was reviewed over 2006-2013. The isolated head-injury patients, patients without hemodynamic compromise on admission (systolic blood pressure > 90 or base excess > -5.0), and those transferred in from another hospital were excluded. The primary outcome measure was 30-day in-hospital mortality. The study period was divided into three phases: 2006-2008 (pre-protocol, 146 patients), 2009-2010 (the implementation of massive transfusion protocol, 85 patients), and 2011-2013 (post massive transfusion protocol, 121 patients). Expected mortality was calculated using the Revised Injury Severity Classification score II. The Standardized Mortality Ratio, as well as the amounts of crystalloids, colloids, and blood products (red blood cells, fresh frozen plasma, platelets) administered prehospital and in the emergency room were compared. RESULTS Of the 354 patients that were included, Standardized Mortality Ratio values decreased (indicating better survival) during the study period from 0.97 (pre-protocol), 0.87 (the implementation of massive transfusion protocol), to 0.79 (post massive transfusion protocol). The amount of crystalloids used in the emergency room decreased from 3870 mL (pre-protocol), 2390 mL (the implementation of massive transfusion protocol), to 2340 mL (post massive transfusion protocol). In these patients, the blood products' (red blood cells, fresh frozen plasma, and platelets together) relation to crystalloids increased from 0.36, 0.70, to 0.74, respectively, in three phases. CONCLUSION During the study period, no other major changes in the protocols on treatment of severely injured patients were implemented. The overall awareness of damage control fluid resuscitation and introduction of massive transfusion protocol in a trauma center has a significant positive effect on the outcome of severely injured patients.
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Affiliation(s)
- T Brinck
- Töölö Trauma Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - L Handolin
- Töölö Trauma Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - R Lefering
- Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Cologne, Germany
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Abstract
PURPOSE OF REVIEW Intravenous fluid is a fundamental component of trauma care and fluid management influences patient outcomes. This narrative review appraises recent clinical studies of fluid therapy in patients with traumatic brain injury (TBI), with respect to its use in volume resuscitation and prevention of secondary injury. RECENT FINDINGS Despite the development of level 1 evidence in fluid resuscitation, in patients with TBI key questions concerning optimal composition and volume remain unanswered. In the absence of randomized trials demonstrating patient outcome differences, clinical practice is often based on physiological principles and surrogate endpoints. There is a physiological rationale why excessive fluid administration and positive fluid balance may increase brain swelling and intracranial pressure (ICP); in some patients, a lower cumulative fluid balance may improve outcomes, but limited human data exist. Resuscitation with 4% albumin in TBI patients in ICU worsens mortality, which may be mediated by increased ICP during the first week after injury. Hypertonic saline and mannitol decrease ICP, but may not improve survival or neurological outcomes. Sodium lactate may be a future therapy for treatment and prevention of secondary brain injury. SUMMARY In patients with TBI, intravenous fluids are integral to management; they may be both a source of harm and a potential therapy to limit secondary brain injury. They should be prescribed in accordance with other pharmaceutical or therapeutic interventions. Refined usage may improve patient outcomes.
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Lecky FE, Omar M, Bouamra O, Jenks T, Edwards A, Battle CE, Evans PA. The effect of preinjury warfarin use on mortality rates in trauma patients: a European multicentre study. Emerg Med J 2015; 32:916-20. [DOI: 10.1136/emermed-2014-203959] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 01/20/2015] [Indexed: 12/17/2022]
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Sherren P, Hussey J, Martin R, Kundishora T, Parker M, Emerson B. Lethal triad in severe burns. Burns 2014; 40:1492-6. [DOI: 10.1016/j.burns.2014.04.011] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 03/03/2014] [Accepted: 04/19/2014] [Indexed: 11/19/2022]
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Jones CW, Keil LG, Weaver MA, Platts-Mills TF. Clinical trials registries are under-utilized in the conduct of systematic reviews: a cross-sectional analysis. Syst Rev 2014; 3:126. [PMID: 25348628 PMCID: PMC4217330 DOI: 10.1186/2046-4053-3-126] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 09/29/2014] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Publication bias is a major threat to the validity of systematic reviews. Searches of clinical trials registries can help to identify unpublished trials, though little is known about how often these resources are utilized. We assessed the usage and results of registry searches reported in systematic reviews published in major general medical journals. METHODS This cross-sectional analysis includes data from systematic reviews assessing medical interventions which were published in one of six major general medical journals between July 2012 and June 2013. Two authors independently examined each published systematic review and all available supplementary materials to determine whether at least one clinical trials registry was searched. RESULTS Of the 117 included systematic reviews, 41 (35%) reported searching a trials registry. Of the 29 reviews which also provided detailed registry search results, 15 (52%) identified at least one completed trial and 18 (62%) identified at least one ongoing trial. CONCLUSIONS Clinical trials registry searches are not routinely included in systematic reviews published in major medical journals. Routine examination of registry databases may allow a more accurate characterization of publication and outcome reporting biases and improve the validity of estimated effects of medical treatments.
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Affiliation(s)
- Christopher W Jones
- Department of Emergency Medicine, Cooper Medical School of Rowan University, One Cooper Plaza, Suite 152, Camden, NJ 08103, USA.
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Abstract
Major surgery and critical illnesses such as sepsis and trauma all disturb normal physiological fluid handling. Intravenous fluid therapy for resuscitation and fluid maintenance is a central part of medical care during these conditions, yet the evidence base supporting practice in this area lacks answers to a number of important questions. Recent research developments include a refinement of our knowledge of the endothelial barrier structure and function and a focus on the potential harm that may be associated with intravenous fluid therapy. Here, we briefly describe the contemporary view of fluid physiology and how this may be disrupted by pathological processes. The important themes in critical illness fluid research are discussed, with a particular focus on two emerging ideas: firstly, that individualising fluid treatment to the patient, their underlying disease state and the phase of that illness may be key to improving clinical outcomes using fluid interventions and, secondly, that fluids should be considered to be drugs, with specific indications and contraindications, dose ranges and potential toxicities.
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Affiliation(s)
- Mark R Edwards
- Department of Anaesthesia, Southampton General Hospital, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton SO16 6YD, UK
- NIHR Southampton Respiratory Biomedical Research Unit, Southampton, UK
| | - Michael G Mythen
- Department of Anaesthesia and Critical Care, University College London Hospitals, London, UK
- University College London, London, UK
- UCLH/UCL NIHR Comprehensive Biomedical Research Centre, London, UK
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Abstract
The major trauma team relies on an efficient, communicative team to ensure patients receive the best quality care. This requires a comprehensive handover, rapid systematic review, and early management of life- and limb-threatening injuries. These multiple injured patients often present with complex conditions in a dynamic situation. The importance of team work, communication, senior decision-making, and documentation cannot be underestimated.
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Affiliation(s)
| | - J C Haycock
- Nottingham University Hospital, Nottingham, UK
| | - D P Forward
- Nottingham University Hospital, Nottingham, UK
| | - C G Moran
- Nottingham University Hospital, Nottingham, UK
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Weisel JW. Monitoring coagulopathies in fluid resuscitation for trauma or surgery. Thromb Res 2014; 134:535-6. [DOI: 10.1016/j.thromres.2014.07.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 07/07/2014] [Accepted: 07/10/2014] [Indexed: 10/25/2022]
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Lawrence MJ, Kumar S, Hawkins K, Boden S, Rutt H, Mills G, Sabra A, Morris RH, Davidson SJ, Badiei N, Brown MR, Williams PR, Evans PA. A new structural biomarker that quantifies and predicts changes in clot strength and quality in a model of progressive haemodilution. Thromb Res 2014; 134:488-94. [DOI: 10.1016/j.thromres.2014.05.039] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 04/15/2014] [Accepted: 05/22/2014] [Indexed: 10/25/2022]
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Asehnoune K, Faraoni D, Brohi K. What's new in management of traumatic coagulopathy? Intensive Care Med 2014; 40:1727-30. [PMID: 25001478 DOI: 10.1007/s00134-014-3388-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2014] [Accepted: 06/27/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Karim Asehnoune
- Pôle PHU3, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, CHU Nantes, 44035, Nantes cedex 1, France,
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Abstract
Current teaching and guidelines suggest that aggressive fluid resuscitation is the best initial approach to the patient with hemodynamic instability. The source of this wisdom is difficult to discern, however, Early Goal Directed therapy (EGDT) as championed by Rivers et al. and the Surviving Sepsis Campaign Guidelines appears to have established this as the irrefutable truth. However, over the last decade it has become clear that aggressive fluid resuscitation leading to fluid overload is associated with increased morbidity and mortality across a diverse group of patients, including patients with severe sepsis as well as elective surgical and trauma patients and those with pancreatitis. Excessive fluid administration results in increased interstitial fluid in vital organs leading to impaired renal, hepatic and cardiac function. Increased extra-vascular lung water (EVLW) is particularly lethal, leading to iatrogenic salt water drowning. EGDT and the Surviving Sepsis Campaign Guidelines recommend targeting a central venous pressure (CVP) > 8 mmHg. A CVP > 8 mmHg has been demonstrated to decrease microcirculatory flow, as well as renal blood flow and is associated with an increased risk of renal failure and death. Normal saline (0.9% salt solution) as compared to balanced electrolyte solutions is associated with a greater risk of acute kidney injury and death. This paper reviews the adverse effects of large volume resuscitation, a high CVP and the excessive use of normal saline.
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Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, 825 Fairfax Av, Suite 410, Norfolk 23507, VA, USA
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Abstract
This article outlines the challenges of identification and management of tissue hypoperfusion as a consequence of haemorrhagic shock in civilian polytrauma cases. It also describes damage resuscitation, but does not cover specific trauma cases such as pregnancy, burns, head injuries, children and elderly trauma.
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Affiliation(s)
- Jakub Kaczynski
- Department of General Surgery, Morriston Hospital, Swansea SA6 6NL.
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Hoffman MD, Pasternak A, Rogers IR, Khodaee M, Hill JC, Townes DA, Scheer BV, Krabak BJ, Basset P, Lipman GS. Medical Services at Ultra-Endurance Foot Races in Remote Environments: Medical Issues and Consensus Guidelines. Sports Med 2014; 44:1055-69. [DOI: 10.1007/s40279-014-0189-3] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Ferrada P, Evans D, Wolfe L, Anand RJ, Vanguri P, Mayglothling J, Whelan J, Malhotra A, Goldberg S, Duane T. Findings of a randomized controlled trial using limited transthoracic echocardiogram (LTTE) as a hemodynamic monitoring tool in the trauma bay. J Trauma Acute Care Surg. 2014;76:31-37; discussion 37-38. [PMID: 24368354 DOI: 10.1097/ta.0b013e3182a74ad9] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND We hypothesize that limited transthoracic echocardiogram (LTTE) is a useful tool to guide therapy during the initial phase of resuscitation in trauma patients. METHODS All highest-level alert patients with at least one measurement of systolic blood pressure less than 100 mm Hg, a mean arterial pressure less than 60 mm Hg, and/or a heart rate greater than 120 beats per minute who arrived to the trauma bay (TB) were randomized to have either LTTE performed (LTTEp) or not performed (non-LTTE) as part of their initial evaluation. Images were stored, and results were reported regarding contractility (good vs. poor), fluid status (empty inferior vena cava [hypovolemic] vs. full inferior vena cava [not hypovolemic]), and pericardial effusion (present vs. absent). Time from TB to operating room, intravenous fluid administration, blood product requirement, intensive care unit admission, and mortality were examined in both groups. RESULTS A total of 240 patients were randomized. Twenty-five patients were excluded since they died upon arrival to the TB, leaving 215 patients in the study. Ninety-two patients were in the LTTEp group with 123 patients in the non-LTTE group. The LTTEp and non-LTTE groups were similar in age (38 years vs. 38.8 years, p = 0.75), Injury Severity Score (ISS) (19.2 vs. 19.0, p = 0.94), Revised Trauma Score (RTS) (5.5 vs. 6.0, p = 0.09), lactate (4.2 vs. 3.6, p = 0.14), and mechanism of injury (p = 0.44). Strikingly, LTTEp had significantly less intravenous fluid than non-LTTE patients (1.5 L vs. 2.5 L, p < 0.0001), less time from TB to operating room (35.6 minutes vs. 79.1 min, p = 0.0006), higher rate of intensive care unit admission (80.4% vs. 67.2%, p = 0.04), and a lower mortality rate (11% vs. 19.5%, p = 0.09). Mortality differences were particularly evident in the traumatic brain injury patients (14.7% in LTTEp vs. 39.5% in non-LTTE, p = 0.03). CONCLUSION LTTE is a useful guide for therapy in hypotensive trauma patients during the early phase of resuscitation. LEVEL OF EVIDENCE Therapeutic study, level II.
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Kaczynski J, Wilczynska M, Fligelstone L, Hilton J. The pathophysiology, diagnosis and treatment of the acute coagulopathy of trauma and shock: a literature review. Eur J Trauma Emerg Surg 2015; 41:259-72. [DOI: 10.1007/s00068-013-0360-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2013] [Accepted: 12/01/2013] [Indexed: 10/25/2022]
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Abstract
Worldwide, trauma is responsible for more than 10,000 deaths each day with hundreds of thousands seriously injured. Current trauma resuscitation strategies are based on supporting haemostasis, maintaining circulating volume and rapidly identifying sites of blood loss. Approaches include hypotensive/hypovolaemic resuscitation, avoidance of colloids and crystalloids, early blood product based resuscitation, early imaging to identify sites of blood loss and damage control surgery. In this paper, we focus on ways to minimise blood loss and preserve the circulating volume. These include minimal movement of the patient, splinting fractures, use of tourniquets, application of local haemostatic dressings/agents, keeping the patient warm and giving tranexamic acid to improve clot strength. The recent CRASH-2 trial provided unequivocal evidence that tranexamic acid reduces mortality in bleeding trauma patients. This will be discussed in detail. When employed as part of a package of care in a well-rehearsed trauma system, these interventions to preserve the remaining circulating volume have the potential to save lives and allow patients to survive until timely definitive haemostasis can occur.
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Affiliation(s)
- A Chesters
- Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, UK
| | - I Roberts
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, UK
| | - T Harris
- Queen Mary, University of London and Bart's Health NHS Trust, London, UK
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Kaczynski J. Resuscitation beyond Advanced Trauma Life Support: damage control. Br J Hosp Med (Lond) 2013; 74:144-8. [PMID: 23665783 DOI: 10.12968/hmed.2013.74.3.144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Jakub Kaczynski
- Department of General Surgery, Morriston Hospital, Swansea, UK.
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Morrison JJ, Ross JD, Poon H, Midwinter MJ, Jansen JO. Intra-operative correction of acidosis, coagulopathy and hypothermia in combat casualties with severe haemorrhagic shock. Anaesthesia 2013; 68:846-50. [PMID: 23724784 DOI: 10.1111/anae.12316] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2013] [Indexed: 11/28/2022]
Abstract
We assessed acidosis, coagulopathy and hypothermia, before and after surgery in 51 combat troops operated on for severe blast injury. Patients were transfused a median (IQR [range]) of 27 (17-38 [5-84]) units of red cell concentrate, 27 (16-38 [4-83]) units of plasma, 2.0 (0.5-3.5 [0-13.0]) units of cryoprecipitate and 4 (2-6 [0-17]) pools of platelets. The pH, base excess, prothrombin time and temperature increased: from 7.19 (7.10-7.29 [6.50-7.49]) to 7.45 (7.40-7.51 [7.15-7.62]); from -9.0 (-13.5 to -4.5 [-28 to -2]) mmol.l⁻¹ to 4.5 (1.0-8.0 [-7 to +11]) mmol.l⁻¹; from 18 (15-21 [9-24]) s to 14 (11-18 [9-21]) s; and from 36.1 (35.1-37.1 [33.0-38.1]) °C to 37.4 (37.0-37.9 [36.0-38.0]) °C, respectively. Contemporary intra-operative resuscitation strategies can normalise the physiological derangements caused by haemorrhagic shock.
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Affiliation(s)
- J J Morrison
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK; US Army Institute of Surgical Research, Fort Sam Houston, San Antonio, Texas, USA
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Affiliation(s)
- M. D. Wiles
- Royal Hallamshire Hospital; Sheffield Teaching Hospitals NHS Foundation Trust; Sheffield, UK
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