J Trauma
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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.
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We have previously shown that blood transfusion in the first 24 hours is an independent predictor of mortality, intensive care unit (ICU) admission, and increased ICU length of stay in the acute trauma setting when controlling for Injury Severity Score, Glasgow Coma Scale score, and age. Indices of shock such as base deficit, serum lactate level, and admission hemodynamic status (systolic blood pressure, heart rate) and admission hematocrit were considered potential confounding variables in that study. The objectives of this study were to evaluate admission anemia and blood transfusion within the first 24 hours as independent predictors of mortality, ICU admission, ICU length of stay (LOS), and hospital LOS, with serum lactate level, base deficit, and shock index (heart rate/systolic blood pressure) as covariates. ⋯ Blood transfusion is confirmed as an independent predictor of mortality, ICU admission, ICU LOS, and hospital LOS in trauma after controlling for severity of shock by admission base deficit, lactate, shock index, and anemia. The use of other hemoglobin-based oxygen-carrying resuscitation fluids (such as human or bovine hemoglobin substitutes) in the acute postinjury period warrants further investigation.
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Tourniquet application is a known means for bleeding prevention in the military prehospital setting. ⋯ Tourniquet application is an effective and easily applied (by medical and nonmedical personnel) method for prevention of exsanguination in the military prehospital setting.
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Evidence suggests that trauma centers treating high volumes of severely injured patients produce lower mortality rates than those with low volumes. However, the effect of individual surgeons' trauma caseload on outcomes has not been studied. This study compares outcomes between high-volume (HV) trauma surgeons admitting many patients with high injury severity, and low-volume (LV) surgeons treating fewer critical patients per year. ⋯ Within a single institution, mortality rates for patients treated by surgeons admitting many severely injured patients were not significantly different from low-volume surgeons' patients, although there was a trend toward higher mortality in the less active surgeons' patients in some subgroups.