Resuscitation experience in the Falkland Islands campaign

Prehospital fluid management of abdominal organ trauma patients--a matched pair analysis

PURPOSE

Severe bleeding after trauma frequently leads to a poor outcome. Prehospital fluid replacement therapy is considered an important primary treatment option. We conducted a retrospective matched pair analysis to assess the influence of prehospital fluid replacement volume on the clinical course of patients with solid abdominal organ trauma.

METHODS

Data were analyzed from 51,425 patients in TraumaRegister DGU® of the German Trauma Society. Inclusion criteria were as follows: injury severity score ≥ 16 points, primary admission, age ≥ 16 years, no isolated brain injury, transfusion of at least one unit of packed red blood cells (pRBCs), and systolic blood pressure ≥ 20 mmHg at the accident site. The patients were divided into "low-volume" (0-1000 ml) and "high-volume" (≥ 1,500 ml) groups according to the matched pair criteria. In each group, 68 patients met the inclusion criteria.

RESULTS

Higher volume in fluid replacement was associated with increased need for transfusion (pRBCs: low-volume: 7.71 units, high-volume: 9.16 units; p = 0.074) and with by trend reduced clotting ability (prothrombin time: low-volume: 71.47 %, high-volume: 66.47 %; p = 0.27). The percentage of patients in shock (systolic blood pressure <90 mmHg) upon admission was equal in the two groups (25.0 %; p = 1). The mortality rate was discretely higher in the high-volume group (low-volume: 11.8 %, high-volume: 19.1 %; p = 0.089).

CONCLUSIONS

Excessive prehospital fluid replacement is able to lead in an increased mortality rate in patients with solid abdominal organ injury. Our results support the concept of restrained fluid replacement in the preclinical treatment of severe trauma patients.

Does increased prehospital replacement volume lead to a poor clinical course and an increased mortality? A matched-pair analysis of 1896 patients of the Trauma Registry of the German Society for Trauma Surgery who were managed by an emergency doctor at the accident site

INTRODUCTION

Severe bleeding after trauma frequently leads to a poor outcome. Prehospital fluid replacement therapy is regarded as an important primary treatment option. Our study aimed to assess the influence of prehospital fluid replacement therapy on the post-traumatic course of severely injured patients in a retrospective analysis of matched pairs.

PATIENTS AND METHODS

The data of 51,425 patients of the Trauma Registry of the German Society for Trauma Surgery were analysed. The following patients were included: Injury Severity Score ≥ 16 points, primary admission, age ≥ 16 years, no isolated brain injury, transfusion of at least one unit of packed red blood cells (pRBC), systolic blood pressure ≥ 60 mmHg at the accident site. The patients were divided into two groups according to the following matched-pair criteria (low-volume: 0-1500 ml prehospital volume replaced; high-volume: ≥ 1501 ml prehospital volume): intubation at the accident site (yes/no), time from injury to hospital ± 10 min., means of rescue (emergency helicopter, MICU), Abbreviated Injury Scale (body regions), injury year, systolic blood pressure and age (years). All patients were managed by an emergency doctor at the accident site.

RESULTS

A total of 948 patients in each group met the inclusion criteria. Increasing replacement volume was associated with an increased need for transfusion (pRBCs: low-volume: 7 units, high-volume: 8.3 units; p<0.001) and a reduced ability to coagulate (prothrombin ratio (PR): low-volume: 68%, high-volume: 61.5%; p<0.001). Patients in shock (systolic BP<90 mmHg) upon admission to the hospital were equally in both groups (25.6%; p=0.98). Significantly higher lethality was observed in cases of increasing volume (low-volume: 22.7%, high-volume: 27.6%; p<0.01).

CONCLUSIONS

Excessive prehospital fluid replacement leads to an increased mortality rate. The results of this study support the concept of restrained volume replacement in the prehospital treatment of patients with severe trauma.

[Control of bleeding in the military environment]

One of the basics of military medicine is the control of haemorrhagic shock. Haemorrhage is the first cause of preventable death in combat, with the adequate control of bleeding being considered as fundamental to estimate the survival of the combatant as well as therapeutic support aimed at minimising blood loss being a challenge within military health logistics. The aim of this work is to review the medical and logistics advances in the treatment of bleeding in the military environment and combat during the latest conflicts, and to describe what is the current contribution of the Spanish Armed Forces and to profile future lines of investigation.

Influence of prehospital fluid resuscitation on patients with multiple injuries in hemorrhagic shock in patients from the DGU trauma registry

Background:

Severe bleeding as a result of trauma frequently leads to poor outcome by means of direct or delayed mechanisms. Prehospital fluid therapy is still regarded as the main option of primary treatment in many rescue situations. Our study aimed to assess the influence of prehospital fluid replacement on the posttraumatic course of severely injured patients in a retrospective analysis of matched pairs.

Materials and Methods:

We reviewed data from 35,664 patients recorded in the Trauma Registry of the German Society for Trauma Surgery (DGU). The following patients were selected: patients having an Injury Severity Score >16 points, who were ≥16 years of age, with trauma, excluding those with craniocerebral injuries, who were admitted directly to the participating hospitals from the accident site. All patients had recorded values for replaced volume and blood pressure, hemoglobin concentration, and units of packed red blood cells given. The patients were matched based on similar blood pressure characteristics, age groups, and type of accident to create pairs. Pairs were subdivided into two groups based on the volumes infused prior to hospitalization: group 1: 0-1500 (low), group 2: ≥2000 mL (high) volume.

Results:

We identified 1351 pairs consistent with the inclusion criteria. Patients in group 2 received significantly more packed red blood cells (group 1: 6.9 units, group 2: 9.2 units; P=0.001), they had a significantly reduced capacity of blood coagulation (prothrombin ratio: group 1: 72%, group 2: 61.4%; P≤0.001), and a lower hemoglobin value on arrival at hospital (group 1: 10.6 mg/dL, group 2: 9.1 mg/dL; P≤0.001). The number of ICU-free days concerning the first 30 days after trauma was significantly higher in group 1 (group 1: 11.5 d, group 2: 10.1 d; P≤0.001). By comparison, the rate of sepsis was significantly lower in the first group (group 1: 13.8%, group 2: 18.6%; P=0.002); the same applies to organ failure (group 1: 36.0%, group 2: 39.2%; P≤0.001).

Conclusion:

The high amounts of intravenous fluid replacement was related to early traumatic coagulopathy, organ failure, and sepsis rate.

[Lethality and outcome in multiple injured patients after severe abdominal and pelvic trauma. Influence of preclinical volume replacement - an analysis of 604 patients from the trauma registry of the DGU]

BACKGROUND

Uncontrollable hemorrhaging after blunt trauma and the resulting hemorrhagic shock is still one of the main causes of death in trauma patients. Starting volume replacement before admission to hospital is one of the main pillars of immediate treatment. The statements concerning the quantity of the preclinically administered fluid are still controversial and have a low level of evidence in the literature. Massive abdominal trauma and unstable pelvic fractures belong to the most relevant causes of hemorrhagic shock. The aim of this study was to analyze the influence of the quantity of the preclinically administered fluid on the posttraumatic course of patients with massive abdominal and pelvic injuries.

PATIENTS AND METHODS

All patients of the trauma registry of the DGU (German Society for Trauma Surgery) who met the following criteria were included: injury severity score ≥16 points, primary admission to hospital, age ≥16 years, initial blood pressure <100 mmHg and transfusion of erythrocyte concentrate (EC). Out of this collective patients with an AIS abdomen ≥4 or an AIS pelvis ≥4 were analyzed. Both groups were divided into 4 subgroups subject to the preclinically infused volume (<1000 ml, 1000-2000 ml, 2001-3000 ml and >3000 ml).

RESULTS

Of the 375 patients with abdominal trauma and 229 patients with pelvic trauma were consistent with the inclusion criteria. In both groups an increasing volume replacement was associated with an increased need for transfusion and a reduction of the coagulation ability (Quick 61% in the case of <1000 ml versus 49.1% in the case of >3000 ml). The rescue time had a relevant influence on the quantity of preclinically infused volume (62 min for <1000 ml versus 88 min for >3000 ml). On admission to hospital the blood pressure values were on average the same in all patients (~ 95 mmHg). With an increasing volume a slight elevation of lethality was found as well as a significant increase of the transfused erythrocyte concentrates, a significant deterioration of coagulation and an increase of patients with mass transfusions.

CONCLUSION

In the case of a preclinical relevant bleeding after blunt pelvic or abdominal trauma moderate volume replacement (<1000 ml) results in an enhancement of the initial coagulation situation and in a reduction in the need for transfusion. The results of this study support the concept of a restrained volume therapy after massive trauma with and bleeding requiring transfusion.

The use of silver-impregnated dressings in blast injuries

This article aims to critically examine the management of military patients who have been the victims of thermal injuries, which have become infected resulting from their inoculation with dirt and foreign bodies during blasts and explosions. In the interests of maintaining confidentiality, the names of NHS trusts, military hospitals and specific military operations have been omitted. This action has been taken in accordance with guidelines from the Nursing and Midwifery Council (2008).