Shock : molecular, cellular, and systemic pathobiological aspects and therapeutic approaches : the official journal the Shock Society, the European Shock Society, the Brazilian Shock Society, the International Federation of Shock Societies
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Time to hemorrhage control is critical, as mortality in patients with severe hemorrhage that arrive to trauma centers with sign of life remains over 40%. Prompt identification and management of severe hemorrhage is paramount to reducing mortality. In traditional US trauma systems, the early hospital course of a severely hemorrhaging patient typically proceeds from the trauma resuscitation bay to the operating room or angiography suite with a potential stop for radiological imaging. ⋯ Even if proven to yield superior outcomes, there are significant obstacles to adopting the HERS in the US. Challenges such as the high cost of building and implementing a HER system, return on investment, and the significant differences between the US and Japan in terms of physician training, trauma center, and reimbursement schemes may render the hybrid ER system to be unfeasible in most current trauma centers. Barriers aside, the Japanese hybrid ER system remains the most novel recent advancement in the quest to reduce potentially preventable mortality from hemorrhage.
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Trauma-induced coagulopathy is associated with very high mortality, and hemorrhage remains the leading preventable cause of death after injury. Directed methods to combat coagulopathy and attain hemostasis are needed. The available literature regarding viscoelastic testing, including thrombelastography (TEG) and rotational thromboelastometry (ROTEM), was reviewed to provide clinically relevant guidance for emergency resuscitation. ⋯ Finally, viscoelastic tests identify fibrinolysis, a finding associated with significantly increased mortality yet one that no conventional coagulation test can reliably detect. Using these parameters, guided resuscitation begins within minutes of a patient's arrival. A growing body of evidence suggests this approach may improve survival while reducing volumes of blood products transfused.
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Multicenter Study Observational Study
Prognosis and Risk Factors of Sepsis Patients in Chinese Icus: A Retrospective Analysis of A Cohort Database.
Sepsis-3 proposed a new definition of septic shock that excluded patients without hyperlactacidemia. The data from China might help to elucidate the prognosis of this special patient group. ⋯ Patients with hypotension but without hyperlactacidemia in the ICU also show a high 28-day mortality, and some clinical factors may affect their prognosis and must be treated carefully in the future.
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Following advances in blood typing and storage, whole blood transfusion became available for the treatment of casualties during World War I. While substantially utilized during World War II and the Korean War, whole blood transfusion declined during the Vietnam War as civilian centers transitioned to blood component therapies. ⋯ Early data suggests equivalent or improved resuscitation and hemostatic markers with whole blood transfusion when compared to balanced blood component therapy. Additional studies are taking place to define the optimal way to utilize low-titer type O whole blood in both prehospital and trauma center resuscitation of bleeding patients.
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Comparative Study
Comparison of Clinical Outcomes with Initial Norepinephrine or Epinephrine for Hemodynamic Support After Return of Spontaneous Circulation.
The optimal vasoactive agent for management of patients with return of spontaneous circulation (ROSC) after cardiac arrest has not yet been identified. The Advanced Cardiac Life Support guidelines recommend initiation of either norepinephrine (NE), epinephrine (EPI), or dopamine (DA) to maintain adequate hemodynamics after ROSC is achieved. The goal of this study is to retrospectively assess the impact of initial vasopressor agent on incidence rate of rearrest, death, or need for additional vasopressor in post-cardiac arrest emergency department (ED) patients. ⋯ These data suggest prospective study of initial vasopressors used for hemodynamic support after ROSC may be warranted. Rates of intra-emergency department refractory shock, rearrest, or death were higher among epinephrine treated patients compared to norepinephrine treated patients in this population. However, inability to control for potential confounding variables in retrospective studies limits the findings. These results are hypothesis generating and further study is warranted.