1. Unique Identifier 96173245
Author Baron BJ; Scalea TM
Institution Department of Emergency Medicine, State University of New York, Health Science Center at Brooklyn, USA.
Title Acute blood loss.
Source Emerg Med Clin North Am 1996 Feb;14(1): p35-55
AbstractAcute blood loss is a common, but often challenging, problem facing emergency physicians. Inadequate or delay in treatment can lead to morbidity or mortality. Standard classifications to quantify blood loss, as well as vital signs alone, are inadequate for guiding therapy. Mechanism of injury, base deficit and blood lactate, central venous oxygen saturation, and oxygen transport parameters should all play a role in deciding the need for further diagnostic studies and resuscitation. Extreme care must be taken to evaluate and resuscitate those with decreased physiologic reserve adequately, such as the elderly. Once bleeding has been identified, expeditious control of bleeding should be accomplished, either operatively or angiographically. Care must be individualized, but adherence to these general guidelines will improve outcome.
2. Unique Identifier 94192361
Author Abou-Khalil B; Scalea TM; Trooskin SZ; Henry SM; Hitchcock R
Institution Department of Surgery, SUNY Health Science Center at Brooklyn.
Title Hemodynamic responses to shock in young trauma patients: need for invasive monitoring [see comments]
Source Crit Care Med 1994 Apr;22(4): p633-9
OBJECTIVE: To determine whether early invasive monitoring is necessary in young trauma patients.
DESIGN: A prospective study.
SETTING: Surgical intensive care unit (ICU) at an inner-city, Level I trauma center. PATIENTS: Thirty-nine patients < 40 yrs of age, who required operative therapy for penetrating trauma and who received > 6 units of intraoperative blood.
INTERVENTIONS: Invasive hemodynamic monitoring, with percutaneous insertion of arterial and pulmonary artery catheters. Vital signs, hemodynamic and oxygen transport values, and laboratory tests were obtained at 1, 8, and 24 hrs postoperatively. Oxygen delivery was increased until a normal serum lactate concentration and a state of nonflow-dependent oxygen consumption were achieved.
MEASUREMENTS AND MAIN RESULTS: Despite normal heart rate, blood pressure, and urine output, only five (15%) patients achieved an optimized state at 1 hr postoperatively. Of the other 34 patients, two patients achieved an optimized state with volume infusion alone and 32 (82%) patients required inotropes. Five (12%) patients never achieved an optimized state and died within hours of their arrival to the ICU. Two other patients achieved an optimized state but died of sepsis and organ failure. The other 32 (82%) patients achieved an optimized state within 24 hrs and survived. The hemodynamic values of survivors at 1 hr postoperatively showed a significantly lower pulmonary vascular resistance and serum lactate concentration, and a significantly higher oxygen delivery and mixed venous oxygen saturation, when compared with the values of nonsurvivors. At 24 hrs postoperatively, survivors also had a significantly lower pulmonary vascular resistance and serum lactate concentration, and significantly higher oxygen delivery than nonsurvivors. Survivors' oxygen consumption was also higher than the oxygen consumption of nonsurvivors.
CONCLUSIONS: Our data demonstrate that young trauma patients have substantial but clinically occult myocardial depression after shock, and most of these patients require inotropes to optimize and clear circulating lactate. Early invasive monitoring is necessary to precisely define the adequacy of the cardiac response and to individually tailor therapy. Patients who do not optimize and clear their lactate within 24 hrs may not survive.
3. Unique Identifier 88259301
Author Scalea TM; Holman M; Fuortes M; Baron BJ; Phillips TF; Goldstein AS; Sclafani SJ; Shaftan GW
Institution Kings County Hospital, SUNY, Health Sciences Center, Brooklyn 11203.
Title Central venous blood oxygen saturation: an early, accurate measurement of volume during hemorrhage.
Source J Trauma 1988 Jun;28(6): p725-32
Accurate and relatively simple monitoring is essential in managing patients with multiple injuries, and becomes particularly important when there is substantial occult blood loss. Tachycardia, said to occur following a 15% blood loss, is generally regarded as the first reliable sign of hemorrhage. However, heart rate is a nonspecific parameter which is affected by factors other than changing intravascular volume. The purpose of this study was to evaluate available means of monitoring volume status and to identify the parameter which is the earliest and most reliable indication of blood loss. Sixteen mongrel dogs were anesthetized and bled by increments of 3% of their total blood volume until the onset of sustained hypotension or a 25% blood loss. All dogs were monitored with a Swan-Ganz catheter and an arterial line. Vital signs, full hemodynamic parameters, and arterial and mixed venous blood gases were measured after each 3% blood loss. Statistical analysis of the data demonstrated that only Cardiac and Mixed Venous Oxygen Saturation showed linearity as function of measure blood loss. Linear regression analysis generated r values that ranged from 0.85-0.99 with a mean of 0.95 for Mixed Venous Oxygen Saturation; r values for Cardiac ranged from 0.39-0.98 with a mean of 0.85. Furthermore, all dogs had increased tissue oxygen extraction after 3-6% blood loss. Because Central Venous Blood Oxygen Saturation mirrors Mixed Venous Oxygen Saturation and is easily and rapidly measured, we extended our study by repeating all of the previously measured parameters, with the addition of CVP blood gases in an unanesthetized animal model.(ABSTRACT TRUNCATED AT 250 WORDS).
4. Title Advanced Trauma Life Support Course, Student Manual.
Source American College of Surgeons, Committee on Trauma, Chicago, 1993.
Unique Identifier 95021533
Author Bickell WH; Wall MJ Jr; Pepe PE; Martin RR; Ginger VF; Allen MK; Mattox KL
Institution Department of Emergency Services, Saint Francis Hospital, Tulsa, Okla.
5. Title Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries [see comments]
Source N Engl J Med 1994 Oct 27;331(17): p1105-9
AbstractBACKGROUND. Fluid resuscitation may be detrimental when given before bleeding is controlled in patients with trauma. The purpose of this study was to determine the effects of delaying fluid resuscitation until the time of operative intervention in hypotensive patients with penetrating injuries to the torso.
METHODS. We conducted a prospective trial comparing immediate and delayed fluid resuscitation in 598 adults with penetrating torso injuries who presented with a pre-hospital systolic blood pressure of < or = 90 mm Hg. The study setting was a city with a single centralized system of pre-hospital emergency care and a single receiving facility for patients with major trauma. Patients assigned to the immediate-resuscitation group received standard fluid resuscitation before they reached the hospital and in the trauma center, and those assigned to the delayed-resuscitation group received intravenous cannulation but no fluid resuscitation until they reached the operating room.
RESULTS. Among the 289 patients who received delayed fluid resuscitation, 203 (70 percent) survived and were discharged from the hospital, as compared with 193 of the 309 patients (62 percent) who received immediate fluid resuscitation (P = 0.04). The mean estimated intraoperative blood loss was similar in the two groups. Among the 238 patients in the delayed-resuscitation group who survived to the postoperative period, 55 (23 percent) had one or more complications (adult respiratory distress syndrome, sepsis syndrome, acute renal failure, coagulopathy, wound infection, and pneumonia), as compared with 69 of the 227 patients (30 percent) in the immediate-resuscitation group (P = 0.08). The duration of hospitalization was shorter in the delayed-resuscitation group.
CONCLUSIONS. For hypotensive patients with penetrating torso injuries, delay of aggressive fluid resuscitation until operative intervention improves the outcome.
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