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Bonanno FG. Management of Hemorrhagic Shock: Physiology Approach, Timing and Strategies. J Clin Med 2022; 12:jcm12010260. [PMID: 36615060 PMCID: PMC9821021 DOI: 10.3390/jcm12010260] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/22/2022] [Accepted: 11/27/2022] [Indexed: 12/30/2022] Open
Abstract
Hemorrhagic shock (HS) management is based on a timely, rapid, definitive source control of bleeding/s and on blood loss replacement. Stopping the hemorrhage from progressing from any named and visible vessel is the main stem fundamental praxis of efficacy and effectiveness and an essential, obligatory, life-saving step. Blood loss replacement serves the purpose of preventing ischemia/reperfusion toxemia and optimizing tissue oxygenation and microcirculation dynamics. The "physiological classification of HS" dictates the timely management and suits the 'titrated hypotensive resuscitation' tactics and the 'damage control surgery' strategy. In any hypotensive but not yet critical shock, the body's response to a fluid load test determines the cut-off point between compensation and progression between the time for adopting conservative treatment and preparing for surgery or rushing to the theater for rapid bleeding source control. Up to 20% of the total blood volume is given to refill the unstressed venous return volume. In any critical level of shock where, ab initio, the patient manifests signs indicating critical physiology and impending cardiac arrest or cardiovascular accident, the balance between the life-saving reflexes stretched to the maximum and the insufficient distal perfusion (blood, oxygen, and substrates) remains in a liable and delicate equilibrium, susceptible to any minimal change or interfering variable. In a cardiac arrest by exsanguination, the core of the physiological issue remains the rapid restoration of a sufficient venous return, allowing the heart to pump it back into systemic circulation either by open massage via sternotomy or anterolateral thoracotomy or spontaneously after aorta clamping in the chest or in the abdomen at the epigastrium under extracorporeal resuscitation and induced hypothermia. This is the only way to prevent ischemic damage to the brain and the heart. This is accomplishable rapidly and efficiently only by a direct approach, which is a crush laparotomy if the bleeding is coming from an abdominal +/- lower limb site or rapid sternotomy/anterolateral thoracotomy if the bleeding is coming from a chest +/- upper limbs site. Without first stopping the bleeding and refilling the heart, any further exercise is doomed to failure. Direct source control via laparotomy/thoracotomy, with the concomitant or soon following venous refilling, are the two essential, initial life-saving steps.
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Affiliation(s)
- Fabrizio G Bonanno
- Department of Surgery, Polokwane Provincial Hospital, Cnr Hospital & Dorp Street, Polokwane 0700, South Africa
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Gupta JF, Arshad SH, Telfer BA, Snider EJ, Convertino VA. Noninvasive Monitoring of Simulated Hemorrhage and Whole Blood Resuscitation. BIOSENSORS 2022; 12:bios12121168. [PMID: 36551134 PMCID: PMC9775873 DOI: 10.3390/bios12121168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 12/03/2022] [Accepted: 12/08/2022] [Indexed: 06/01/2023]
Abstract
Hemorrhage is the leading cause of preventable death from trauma. Accurate monitoring of hemorrhage and resuscitation can significantly reduce mortality and morbidity but remains a challenge due to the low sensitivity of traditional vital signs in detecting blood loss and possible hemorrhagic shock. Vital signs are not reliable early indicators because of physiological mechanisms that compensate for blood loss and thus do not provide an accurate assessment of volume status. As an alternative, machine learning (ML) algorithms that operate on an arterial blood pressure (ABP) waveform have been shown to provide an effective early indicator. However, these ML approaches lack physiological interpretability. In this paper, we evaluate and compare the performance of ML models trained on nine ABP-derived features that provide physiological insight, using a database of 13 human subjects from a lower-body negative pressure (LBNP) model of progressive central hypovolemia and subsequent progressive restoration to normovolemia (i.e., simulated hemorrhage and whole blood resuscitation). Data were acquired at multiple repressurization rates for each subject to simulate varying resuscitation rates, resulting in 52 total LBNP collections. This work is the first to use a single ABP-based algorithm to monitor both simulated hemorrhage and resuscitation. A gradient-boosted regression tree model trained on only the half-rise to dicrotic notch (HRDN) feature achieved a root-mean-square error (RMSE) of 13%, an R2 of 0.82, and area under the receiver operating characteristic curve of 0.97 for detecting decompensation. This single-feature model's performance compares favorably to previously reported results from more-complex black box machine learning models. This model further provides physiological insight because HRDN represents an approximate measure of the delay between the ABP ejected and reflected wave and therefore is an indication of cardiac and peripheral vascular mechanisms that contribute to the compensatory response to blood loss and replacement.
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Affiliation(s)
- Jay F. Gupta
- Lincoln Laboratory, Massachusetts Institute of Technology, Lexington, MA 02421, USA
| | - Saaid H. Arshad
- Lincoln Laboratory, Massachusetts Institute of Technology, Lexington, MA 02421, USA
| | - Brian A. Telfer
- Lincoln Laboratory, Massachusetts Institute of Technology, Lexington, MA 02421, USA
| | - Eric J. Snider
- U.S. Army Institute of Surgical Research, San Antonio, TX 78234, USA
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A review of treatments for non-compressible torso hemorrhage (NCTH) and internal bleeding. Biomaterials 2022; 283:121432. [DOI: 10.1016/j.biomaterials.2022.121432] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 01/26/2022] [Accepted: 02/17/2022] [Indexed: 12/12/2022]
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Zhou S, Xie J, Yu C, Feng Z, Cheng K, Ma J, Wang Y, Duan C, Zhang Y, Jin B, Yin W, Zhuang R. CD226 deficiency promotes glutaminolysis and alleviates mitochondria damage in vascular endothelial cells under hemorrhagic shock. FASEB J 2021; 35:e21998. [PMID: 34669985 DOI: 10.1096/fj.202101134r] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/23/2021] [Accepted: 10/04/2021] [Indexed: 12/18/2022]
Abstract
Hemorrhagic shock (HS) is common in clinical emergencies, leading to millions of deaths each year globally. CD226 is a costimulatory adhesion molecule expressed on both immune cells and endothelial cells (ECs) to regulate their metabolic activity and function. As endothelial dysfunction occurs after HS, the roles CD226 plays in vascular EC metabolism were investigated. CD226fl/fl Tekcre mice were adopted to achieve vascular EC-specific knockout of CD226, and subjected to HS modelling. Serum levels of crucial intermediate metabolites were evaluated through liquid chromatography-mass spectrometry analysis. Human umbilical vein ECs (HUVECs) were used to study the effects of CD226 under hypoxia in vitro. Seahorse analysis evaluated the cellular glycolysis and mitochondria bioenergetics. Results showed that CD226 deficiency in vascular ECs alleviated HS-induced intestinal damage and inflammatory response in mice. Animal studies indicated an improved energy metabolism when CD226 was knocked out in ECs after HS, as evidenced by enhanced glutamine-glutamate metabolism and decreased lactic acid levels. Glut-1 was upregulated in mouse vascular ECs after HS and HUVECs under hypoxia, combined with decreased CD226. Moreover, HUVECs with CD226 knockdown exhibited relieved mitochondrial damage and early apoptosis under hypoxia, whereas CD226 overexpression showed opposite effects. Seahorse analysis showed that downregulated CD226 significantly increased mitochondrial ATP production and glucose uptake in HUVECs under hypoxia. Additionally, Erk/PHD2 signaling-mediated HIF-1α/Glut-1 and HIF-2α/ASCT2 pathways were involved in CD226 regulation on HUVEC glutaminolysis after hypoxia. Hence, CD226 deficiency promotes bypass energy supply to vascular ECs under ischemic or hypoxic stress, to ameliorate the stress-mediated metabolic disturbance.
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Affiliation(s)
- Shangxun Zhou
- Department of Immunology, Fourth Military Medical University, Xi'an, China.,Department of Emergency, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Jiangang Xie
- Department of Immunology, Fourth Military Medical University, Xi'an, China.,Department of Emergency, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Chaoping Yu
- Department of Immunology, Fourth Military Medical University, Xi'an, China.,Department of Emergency, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Zhusheng Feng
- Department of Emergency, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Kun Cheng
- Department of Immunology, Fourth Military Medical University, Xi'an, China
| | - Jingchang Ma
- Department of Immunology, Fourth Military Medical University, Xi'an, China
| | - Yuling Wang
- Department of Immunology, Fourth Military Medical University, Xi'an, China
| | - Chujun Duan
- Department of Emergency, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Yuan Zhang
- Institute of Medical Research, Northwestern Polytechnical University, Xi'an, China
| | - Boquan Jin
- Department of Immunology, Fourth Military Medical University, Xi'an, China
| | - Wen Yin
- Department of Emergency, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Ran Zhuang
- Department of Immunology, Fourth Military Medical University, Xi'an, China.,Institute of Medical Research, Northwestern Polytechnical University, Xi'an, China
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Zhu J, Parsons JT, Yang Y, Martin E, Brophy DF, Spiess BD. Platelet and White Cell Reactivity to Top-Load Intravenous Perfluorocarbon Infusion in Healthy Sheep. J Surg Res 2021; 267:342-349. [PMID: 34192613 DOI: 10.1016/j.jss.2021.05.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 04/20/2021] [Accepted: 05/25/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Perfluorocarbon emulsions (PFCs) are intravenous artificial oxygen carriers with enhanced gas solubility. As lipid micelle nanoparticle emulsions, PFCs may have a class effect that causes degrees of thrombocytopenia. Understanding the extent of the platelet effects, including mechanism and potential inflammation after PFC infusion, is important for safe human trials. METHODS Normal sheep (Dorper) were infused with 5 mL/kg of Oxygent (w/v 60% PFC) or Perftoran (w/v 20% PFC). Controls received 6% Hetastarch or were naive. Blood samples were analyzed from baseline, time 0 (the end of infusion), 3 and 24 hours, and 4 and 7 days. Platelet count, plateletcrit, mean platelet volume, platelet distribution width, and CD-62p (a platelet activation-dependent membrane protein) were measured. Neutrophils, monocytes, and total white blood cell counts were analyzed. RESULTS In these inflammatory cell lines, there were no consistent changes or cellular activation after PFC infusion. A decrease (<10% from baseline and naive controls) in platelet count was seen on day 4 after Oxygent infusion (3 g/kg), which recovered by day 7. No platelet effect was seen in Perftoran (1 g/kg). Plateletcrit, mean platelet volume, and platelet distribution width did not change significantly at any time point among the groups. CD-62p, ADP, and collagen aggregometry showed no significant change in platelet function. CONCLUSION There was no evidence of overall reduction in platelet number, or any correlation with the change in platelet activation or inhibition. Therefore, the risk of increased thrombosis/bleeding after PFC intravenous infusion is low in this non-trauma sheep model.
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Affiliation(s)
- Jiepei Zhu
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida 32610.
| | - J Travis Parsons
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida 32610
| | - Yang Yang
- Department of Biostatistics, University of Florida College of Public Health & Health Professions and College of Medicine, Gainesville, Florida 32611
| | - Erika Martin
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia 23298
| | - Donald F Brophy
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia 23298
| | - Bruce D Spiess
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida 32610
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Abstract
Hemorrhagic shock can be mitigated by timely and accurate resuscitation designed to restore adequate delivery of oxygen (DO2) by increasing cardiac output (CO). However, standard care of using systolic blood pressure (SBP) as a guide for resuscitation may be ineffective and can potentially be associated with increased morbidity. We have developed a novel vital sign called the compensatory reserve measurement (CRM) generated from analysis of arterial pulse waveform feature changes that has been validated in experimental and clinical models of hemorrhage. We tested the hypothesis that thresholds of DO2 could be accurately defined by CRM, a noninvasive clinical tool, while avoiding over-resuscitation during whole blood resuscitation following a 25% hemorrhage in nonhuman primates. To accomplish this, adult male baboons (n = 12) were exposed to a progressive controlled hemorrhage while sedated that resulted in an average (± SEM) maximal reduction of 508 ± 18 mL of their estimated circulating blood volume of 2,130 ± 60 mL based on body weight. CRM increased from 6 ± 0.01% at the end of hemorrhage to 70 ± 0.02% at the end of resuscitation. By linear regression, CRM values of 6% (end of hemorrhage), 30%, 60%, and 70% (end of resuscitation) corresponded to calculated DO2 values of 5.9 ± 0.34, 7.5 ± 0.87, 9.3 ± 0.76, and 11.6 ± 1.3 mL O2·kg·min during resuscitation. As such, return of CRM to ∼65% during resuscitation required only ∼400 mL to restore SBP to 128 ± 6 mmHg, whereas total blood volume replacement resulted in over-resuscitation as indicated by a SBP of 140 ± 7 mmHg compared with an average baseline value of 125 ± 5 mmHg. Consistent with our hypothesis, thresholds of calculated DO2 were associated with specific CRM values. A target resuscitation CRM value of ∼65% minimized the requirement for whole blood while avoiding over-resuscitation. Furthermore, 0% CRM provided a noninvasive metric for determining critical DO2 at approximately 5.3 mL O2·kg·min.
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Fresh frozen plasma attenuates lung injury in a novel model of prolonged hypotensive resuscitation. J Trauma Acute Care Surg 2021; 89:S118-S125. [PMID: 32282752 DOI: 10.1097/ta.0000000000002719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hemorrhagic shock remains a leading cause of early death among severely injured in both civilian and military settings. As future military operations will require strategies allowing prolonged field care of the injured, we sought to develop an in vivo model of prolonged hypotensive resuscitation (PHR) and to evaluate the role of plasma-based resuscitation in this model. We hypothesized that resuscitation with fresh frozen plasma (FFP) would mitigate lung injury when compared with Hextend in a rodent model of PHR. METHODS Mice underwent laparotomy and hemorrhagic shock (mean arterial blood pressure, 35 ± 5 mm Hg × 90 minutes) followed by PHR with either FFP or Hextend to maintain a mean arterial blood pressure of 55 mm Hg to 60 mm Hg for 6 hours. Sham animals underwent cannulation only. At the end of 6 hours, animals were euthanized, and lung tissue harvested for measurement of histopathologic injury, inflammation and permeability using hematoxylin and eosin staining, myeloperoxidase immunofluorescence staining and Evans Blue dye. Pulmonary syndecan-1 immunostaining was assessed as an indicator of endothelial cell integrity. RESULTS All animals in the FFP, Hextend, and sham groups survived to the end of resuscitation. Resuscitation with FFP mitigated lung histopathologic injury compared with Hextend (histologic injury score of 4.38 ± 2.07 vs. 7.5 ± 0.93, scale of 0-9, p = 0.002) and was comparable to shams (histologic injury score of 4.0 ± 1.93, scale of 0-9, p = 0.99). Fresh frozen plasma also reduced lung inflammation (0.116 ± 0.044 vs. 0.308 ± 0.054 relative fluorescence of myeloperoxidase, p = 0.002) and restored pulmonary syndecan-1 (0.514 ± 0.061 vs. 0.059 ± 0.021, relative syndecan-1 fluorescence, p < 0.001) when compared with Hextend. Consistently, FFP mitigated lung hyperpermeability compared with Hextend (7.30 ± 1.34 μg vs. 14.91 ± 5.55 μg Evans blue/100 mg lung tissue, p = 0.005). CONCLUSION We have presented a novel model of PHR of military relevance to the prolonged field care environment. In this model, FFP maintains its pulmonary protective effects using a PHR strategy compared with Hextend, which supports the need for further development and implementation of plasma-based resuscitation in the forward environment. LEVEL OF EVIDENCE Basic science.
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Blood product transfusion during air medical transport: A needs assessment. CAN J EMERG MED 2020; 22:S67-S73. [DOI: 10.1017/cem.2020.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
ABSTRACTObjectivesEarly administration of blood products to patients with hemorrhagic shock has a positive impact on morbidity and mortality. Smaller hospitals may have limited supply of blood, and air medical systems may not carry blood. The primary outcome is to quantify the number of patients meeting established physiologic criteria for blood product administration and to identify which patients receive and which ones do not receive it due to lack of availability locally.MethodsElectronic patient care records were used to identify a retrospective cohort of patients undergoing emergent air medical transport in Ontario, Canada, who are likely to require blood. Presenting problems for blood product administration were identified. Physiologic data were extracted with criteria for transfusion used to identify patients where blood product administration is indicated.ResultsThere were 11,520 emergent patient transports during the study period, with 842 (7.3%) where blood product administration was considered. Of these, 290 met established physiologic criteria for blood products, with 167 receiving blood, of which 57 received it at a hospital with a limited supply. The mean number of units administered per patient was 3.5. The remaining 123 patients meeting criteria did not receive product because none was unavailable.ConclusionIndications for blood product administration are present in 2.5% of patients undergoing time-sensitive air medical transport. Air medical services can enhance access to potentially lifesaving therapy in patients with hemorrhagic shock by carrying blood products, as blood may be unavailable or in limited supply locally in the majority of patients where it is indicated.
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Contemporary resuscitation of hemorrhagic shock: What will the future hold? Am J Surg 2020; 220:580-588. [PMID: 32409009 PMCID: PMC7211588 DOI: 10.1016/j.amjsurg.2020.05.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 04/28/2020] [Accepted: 05/07/2020] [Indexed: 02/07/2023]
Abstract
Resuscitation of the critically ill patient with fluid and blood products is one of the most widespread interventions in medicine. This is especially relevant for trauma patients, as hemorrhagic shock remains the most common cause of preventable death after injury. Consequently, the study of the ideal resuscitative product for patients in shock has become an area of great scientific interest and investigation. Recently, the pendulum has swung towards increased utilization of blood products for resuscitation. However, pathogens, immune reactions and the limited availability of this resource remain a challenge for clinicians. Technologic advances in pathogen reduction and innovations in blood product processing will allow us to increase the safety profile and efficacy of blood products, ultimately to the benefit of patients. The purpose of this article is to review the current state of blood product based resuscitative strategies as well as technologic advancements that may lead to safer resuscitation.
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Zong ZW, Qin H, Chen SX, Yang JZ, Yang L, Zhang L, Du WQ, Zhong X, Zhou RJ, Tan D, Wu H. Chinese expert consensus on the treatment of modern combat-related spinal injuries. Mil Med Res 2019; 6:6. [PMID: 30786926 PMCID: PMC6381715 DOI: 10.1186/s40779-019-0196-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 02/07/2019] [Indexed: 12/12/2022] Open
Abstract
The battlefield treatments of spinal and spinal cord injury vary from civilian settings. However, there is no unified battlefield treatment guidelines for spine trauma in PLA. An expert consensus is reached, based on spine trauma epidemiology and the concepts of battlefield treatment combined with the existing levels of military medical care in modern warfare. Since the specialized treatment for spine trauma are no significant difference between civilian settings and modern war, the first aid, emergency treatment and early treatment of spine trauma are introduced separately in three levels in this consensus. In Level I facilities, the fast and accurate evaluation of spine trauma followed by fixation and stabilization are recommended during the first-aid stage. Re-evaluation, further treatment for possible hemorrhagic shock, dyspnea and infection are recommended at Level II facilities. At Level III facilities, it is recommended to strengthen the intensive care and the prevention of urinary system and lung infection for the wounded with severe spinal injury, however, spinal surgery is not recommended in a battlefield hospital. The grading standard for evidence evaluation and recommendation was used to reach this expert consensus.
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Affiliation(s)
- Zhao-Wen Zong
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, Chongqing, 400038, China.
| | - Hao Qin
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, Chongqing, 400038, China
| | - Si-Xu Chen
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, Chongqing, 400038, China
| | - Jia-Zhi Yang
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, Chongqing, 400038, China
| | - Lei Yang
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, Chongqing, 400038, China
| | - Lin Zhang
- Department of Tactical Health Service, NCO School of Army Medical University, Shijiazhuang, 050000, China
| | - Wen-Qiong Du
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, Chongqing, 400038, China
| | - Xin Zhong
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, Chongqing, 400038, China
| | - Ren-Jie Zhou
- Xinqiao Hospital, Army Medical University, Chongqing, 400037, China
| | - Dan Tan
- Xinqiao Hospital, Army Medical University, Chongqing, 400037, China
| | - Hao Wu
- Xinqiao Hospital, Army Medical University, Chongqing, 400037, China
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Spear AM, Lawton G, Staruch RMT, Rickard RF. Regenerative medicine and war: a front-line focus for UK defence. NPJ Regen Med 2018; 3:13. [PMID: 30155273 PMCID: PMC6104070 DOI: 10.1038/s41536-018-0053-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 06/19/2018] [Accepted: 07/24/2018] [Indexed: 12/15/2022] Open
Abstract
The recent prolonged conflicts in Iraq and Afghanistan saw the advancement of deployed trauma care to a point never before seen in war. The rapid translation of lessons from combat casualty care research, facilitated by an appetite for risk, contributed to year-on-year improvements in care of the injured. These paradigms, however, can only ever halt the progression of damage. Regenerative medicine approaches, in contrast, hold a truly disruptive potential to go beyond the cessation of damage from blast or ballistic trauma, to stimulate its reversal, and to do so from a very early point following injury. The internationally distributed and, in parts austere environments in which operational medical care is delivered provide an almost unique challenge to the development and translation of regenerative medicine technologies. In parallel, however, an inherent appetite for risk means that Defence will always be an early adopter. In focusing our operational priorities for regenerative medicine, the authors conducted a review of the current research landscape in the UK and abroad and sought wide clinical opinion. Our priorities are all applicable very far forward in the patient care pathway, and are focused on three broad and currently under-researched areas, namely: (a) blood, as an engineered tissue; (b) the mechanobiology of deep tissue loss and mechanobiological approaches to regeneration, and; (c) modification of the endogenous response. In focusing on these areas, we hope to engender the development of regenerative solutions for improved functional recovery from injuries sustained in conflict.
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Affiliation(s)
- Abigail M. Spear
- Defence Science & Technology Laboratory, Porton Down, Salisbury, UK
| | - Graham Lawton
- Academic Department of Military Surgery & Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - Robert M. T. Staruch
- Academic Department of Military Surgery & Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - Rory F. Rickard
- Academic Department of Military Surgery & Trauma, Royal Centre for Defence Medicine, Birmingham, UK
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Zong ZW, Chen SX, Qin H, Liang HP, Yang L, Zhao YF. Chinese expert consensus on echelons treatment of pelvic fractures in modern war. Mil Med Res 2018; 5:21. [PMID: 29970166 PMCID: PMC6029371 DOI: 10.1186/s40779-018-0168-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 06/13/2018] [Indexed: 01/18/2023] Open
Abstract
The characteristics and treatment of pelvic fractures vary between general conditions and modern war. An expert consensus has been reached based on pelvic injury epidemiology and the concepts of battlefield treatment combined with the existing levels of military medical care in modern warfare. According to this consensus, first aid, emergency treatment and early treatment of pelvic fractures are introduced in three separate levels. In Level I facilities, simple triage and rapid treatment following the principles of advanced trauma life support are recommended to evaluate combat casualties during the first-aid stage. Re-evaluation, further immobilization and fixation, and hemostasis are recommended at Level II facilities. At Level III facilities, the main components of damage control surgery are recommended, including comprehensive hemostasis, a proper resuscitation strategy, the treatment of concurrent visceral and blood vessel damage, and battlefield intensive care. The grading standard for evidence evaluation and recommendation was used to reach this expert consensus.
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Affiliation(s)
- Zhao-Wen Zong
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, ChongQing, 400038, China.
| | - Si-Xu Chen
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, ChongQing, 400038, China
| | - Hao Qin
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, ChongQing, 400038, China
| | - Hua-Ping Liang
- First Department, Research Institute of Surgery, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Lei Yang
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, ChongQing, 400038, China
| | - Yu-Feng Zhao
- Department of Trauma Surgery, Daping Hospital, Army Medical University, ChongQing, 400042, China
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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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