J Trauma
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Hypertonic saline solutions, with or without added colloid, have received extensive evaluation as volume expanders in both animal studies and clinical trials. Most studies have used 7.5% NaCl/6% dextran 70 (HSD). HSD's primary mechanism of action is rapid osmotic mobilization of cellular water into the blood volume. ⋯ Animal studies of immune function suggest that increased osmolarity prevents T-cell depression and decreases neutrophil activation. Several perioperative and eight randomized, blinded trauma trials have shown safety and reduced volume needs and suggest increased survival, particularly in head- and penetrating-injury patients. Infusion rates for HSD of 10 to 20 minutes may be recommended for the initial resuscitation of hypotensive trauma.
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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.
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Comparative Study
Complications of preinjury warfarin use in the trauma patient.
The frequency of use of warfarin anticoagulation increases significantly in the elderly population. It remains controversial whether this puts these patients at increased risk for hemorrhagic complications after trauma. ⋯ We conclude that the preinjury use of warfarin does not place the trauma patient at increased risk for fatal hemorrhagic complications in the absence of head trauma. Furthermore, the presence of a head trauma alone is not predictive of mortality. However, the presence of intracranial injury is strongly associated with a mortality rate that is significantly higher than patients with head trauma who are not taking warfarin. LOC is also associated with mortality, but the absence of loss of consciousness does not reliably indicate the absence of intracranial injury or risk of death.
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The major cause of late death in patients sustaining major trauma relates to the development of progressive organ failure. Recent studies suggest that trauma victims are rendered susceptible to the development of organ failure because antecedent shock/resuscitation renders them susceptible to an exaggerated immune response to late inflammatory stimuli, the so-called two-hit hypothesis. ⋯ Interventions such as antioxidant therapy and hypertonic saline resuscitation have a rational basis for use and have been shown to be effective in a rodent two-hit lung injury model. These studies suggest potential use in the critically ill trauma patient population.
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Vigorous intravenous fluid resuscitation has become widely accepted as the optimum management of hemorrhagic shock in trauma. There is now, however, sufficient evidence for this position to be reviewed. ⋯ It has been suggested that overresuscitation with intravenous fluids may worsen hemorrhage. This article discusses the possible adverse effects of "conventional" resuscitation and examines the evidence to support alternative treatment modalities.