J Trauma
-
Burn injury remains a constant source of morbidity and mortality in the military environment. The logistic constraints of combat casualty care can make it impossible to provide the large volumes of crystalloid typically used for burn resuscitation. Unlike penetrating trauma, the immediate and sustained fluid requirements necessary for resuscitation of thermal injury preclude the use of limited or hypotensive resuscitation. ⋯ Although strategies such as early use of colloids or hypertonic saline may not reduce morbidity or mortality when compared with large-volume infusions of lactated Ringer's, they can be volume sparing for some hours and sustain life until more definitive therapy is initiated. An intriguing hypothesis is that oral resuscitation can effectively restore plasma volume after thermal injury. We present data from recent experiments of gastric and intestinal infusions of an oral rehydration solution in a porcine burn model that demonstrates restoration of plasma volumes and improvement in hemodynamic parameters associated with significant gastric emptying and intestinal absorption.
-
Traumatic combat injuries differ from those encountered in the civilian setting in terms of epidemiology, mechanism of wounding, pathophysiologic trajectory after injury, and outcome. Except for a few notable exceptions, data sources for combat injuries have historically been inadequate. Although the pathophysiologic process of dying is the same (i.e., dominated by exsanguination and central nervous system injury) in both the civilian and military arenas, combat trauma has unique considerations with regard to acute resuscitation, including (1) the high energy and high lethality of wounding agents; (2) multiple causes of wounding; (3) preponderance of penetrating injury; (4) persistence of threat in tactical settings; (5) austere, resource-constrained environment; and (5) delayed access to definitive care. Recognition of these differences can help bring focus to resuscitation research for combat settings and can serve to foster greater civilian-military collaboration in both basic and transitional research.
-
In general, the Canadian Forces follow widely accepted principles of fluid resuscitation. These are simply guidelines for fluid resuscitation, and the Canadian Forces currently do not have an absolute doctrine that the clinician in the field must follow. ⋯ Ringer's lactate is the primary resuscitation fluid that is used. Emphasis is placed on attempting to control ongoing hemorrhage specifically either with direct pressure, surgical control, or splinting of long bone or pelvic fractures at the earliest possible stage.
-
Reactive species of oxygen have been implicated as being important mediators in a variety of pathologic conditions, including burns, various forms of ischemia/reperfusion injury, and hemorrhagic shock. Pyruvate, an intermediate in the metabolism of glucose, is a potent reactive species of oxygen scavenger. Pyruvate, however, is unstable in aqueous solutions, and has not been developed as a therapeutic agent. ⋯ Ringer's ethyl pyruvate solution (REPS) has been evaluated in a number of preclinical studies using animal models of mesenteric ischemia/reperfusion injury, hemorrhagic shock, and acute endotoxemia. Treatment with REPS, when compared with treatment with Ringer's lactate solution, has been shown to be able to improve survival and decrease expression of proinflammatory mediators. REPS warrants further evaluation for the resuscitation of patients with hemorrhagic shock.
-
The systemic inflammation that occurs in shock states is believed to promote overexuberant microcirculatory activation, the release of toxic proteases and oxygen radicals causing microvascular damage, and subsequent tissue and organ injury. Although shock-associated microvascular failure is often unresolved after standard resuscitation, hypertonic saline (HTS) appears to reduce microvascular collapse, restoring vital nutritional blood flow. ⋯ Furthermore, fewer cellular interactions have been correlated with attenuation in microvascular wall permeability after resuscitation with HTS. Better characterization of microcirculatory effects by hypertonic saline may provide mechanisms for improved morbidity and mortality associated with hypertonic resuscitation.