J Trauma
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A number of oxygen therapeutics have completed safety trials and are now undergoing efficacy evaluation in multicenter phase III trials in North America and Europe. There are numerous potential advantages of these solutions when compared with packed red blood cells. ⋯ A few problems remain, including short biologic half-life, which may limit the application to times when the patient is most acutely anemic (i.e., in the intraoperative or immediate perioperative phase) or for emergent use. Nevertheless, a safe, effective alternative therapy providing oxygen delivery characteristics comparable to red blood cells may soon be available that could have significant impact on the way that we resuscitate trauma patients.
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Medical training in the Israel Defense Forces (IDF) is currently based on the principles of the Advanced Trauma Life Support course of the American College of Surgeons termed Military Trauma Life Support. The Advanced Trauma Life Support guidelines provide a systematic standardized approach to the treatment of trauma casualties that has been very successful in civilian trauma. On the battlefield, however, these guidelines have been modified according to the combat environment. ⋯ In uncontrolled hemorrhagic shock, where internal bleeding has temporarily stopped because of hypotension, vasoconstriction, and thrombus formation, aggressive fluid resuscitation with lactated Ringer's solution to achieve normal hemodynamic parameters is prohibited, because it may induce internal rebleeding and hemodynamic decompensation. When evacuation time exceeds 60 minutes, the use of crystalloids and colloids is indicated. If brain injury is suspected, fluid resuscitation should be aimed toward normalization of hemodynamic parameters.
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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.
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Resuscitation can exacerbate cellular injury caused by hemorrhagic shock, and the type of fluid used for resuscitation may play an important role in this injury. Unlike some factors in the treatment of combat casualty, the method of resuscitation is under our control. The prevention of cellular injury through wiser resuscitation strategies would be more advantageous than attempting complex immunomodulation after the damage has already occurred. ⋯ Hypertonic fluids cause suppression of neutrophil activation and a milder increase in the expression of cell injury markers compared with isotonic fluids. The effect of various resuscitation fluids on core cellular functions such as gene regulation is also summarized in this article. Finally, because of the uniqueness of combat care, a set of new recommendations for initial fluid resuscitation of combat casualties is proposed.
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Hemorrhage remains the primary cause of death on the battlefield in conventional warfare. With modern combat operations leading to the likelihood of significant time delays in air evacuation of casualties and long transport times, the immediate goals of the Army's Science and Technology Objectives in Resuscitation are to develop limited- or small-volume fluid resuscitation strategies, including permissive hypotension, for the treatment of severe hemorrhage to improve battlefield survival and prevent early and late deleterious sequelae. As an example, the U. ⋯ In addition, preliminary studies have used HSD under hypotensive resuscitation conditions, and it has been administered through intraosseous infusion devices for vascular access. This research suggests that many of the difficulties and concerns associated with fluid resuscitation for treating significant hemorrhage in the field can be overcome. For the military, such observations have important implications toward the development of optimal fluid resuscitation strategies under austere battlefield conditions for stabilization of the combat casualty.