1/26. Civilian versus military trauma dogma: who do you trust?Combat trauma differs from its peacetime counterpart by involving a different spectrum of injuries, occurring in austere environments, dealing with mass casualties, and embodying inherent treatment delays. Thus, civilian trauma practices may be inappropriate in certain combat settings. A review of historical as well as current vivilian and military data is presented for four trauma topics (military antishock trousers, wound debridement, colon wounds, fluid resuscitation) in which civilian and military principles have clashed. The following recommendations are made. (1) Military antishock trousers are still useful in a combat setting. (2) Soft-tissue wound management should be directed by the wound rather than by the weapon. (3) Cautious avoidance of colostomy may be indicated in certain wartime colon wounds. (4) The majority of combat casualties require early vigorous fluid resuscitation. When civilian trauma experience challenges military dogma, it must be carefully considered before being applied to a combat setting.- - - - - - - - - - ranking = 1keywords = shock (Clic here for more details about this article) |
2/26. Deep venous thrombosis in the pediatric trauma population: an unusual event: report of three cases.The incidence of deep venous thrombosis (DVT) in the pediatric population has been reported to be lower than in adults. Pediatric trauma patients have predisposing risk factors for DVT similar to those in the general trauma population. We reviewed the records of 2746 children under 16 years of age admitted to our Level I pediatric trauma service from 1989 to 1997. Only three cases of DVT were documented, all adolescents. DVT was located in the upper (n = 1) and lower (n = 1) extremity venous system. One patient presented with pulmonary embolism alone without identifiable DVT. risk factors found were venous system manipulations, including atriocaval shunt, subclavian central line, and hyperinflated medical antishock trousers garment. Therapy consisted of heparin followed by warfarin anticoagulation. A vena cava filter was inserted in one patient for whom systemic anticoagulation was contraindicated. No DVT was seen in 1123 closed head injury patients or 29 spinal cord injury patients without associated risk factors. The thrombotic risk in pediatric trauma patients is low. Routine screening or prophylaxis is not indicated except for patients who are likely to remain immobile for an extended period of time and require prolonged rehabilitation, have venous manipulations, or present with clinical symptoms. Hematologic evaluation in patients with diagnosed DVT is necessary to identify individual risk factors.- - - - - - - - - - ranking = 0.5keywords = shock (Clic here for more details about this article) |
3/26. Hepatic glycogen staining. Applications in injury survival time and child abuse.Hepatic glycogen stores have long been known to decrease with starvation, trauma, acute stress, and shock. In this study, hepatic tissue was examined in 122 decedents ranging in age from 1 to 88 years who died of a variety of causes. Hepatic tissue was stained for glycogen/carbohydrates using the Best's carmine and/or period acid-Schiff (PAS)-alcian blue methods in 121 cases. The liver samples were evaluated for amount of staining, staining around hepatic injuries (if present), and presence of histologic abnormalities. Prominence of staining was decreased with increasing survival times after injury (P=.0001) and increasing postmortem interval. Staining along the edges of hepatic injuries was decreased in antemortem injuries but not in postmortem-induced injuries (P<.0001). If used in conjunction with circumstantial and autopsy information, hepatic glycogen/carbohydrate staining using the Best's carmine and PAS-alcian blue methods could greatly aid in the determination of injury survival times and the vital nature of questionable injuries in child deaths and other cases.- - - - - - - - - - ranking = 0.5keywords = shock (Clic here for more details about this article) |
4/26. Maternal persistent vegetative state with successful fetal outcome.A woman suffered from massive blunt injuries in a motor vehicle accident at a presumed 4 weeks' gestation, but she successfully carried the fetus for an additional 29 weeks. Premature labor began at 33 weeks' gestation and a live 1,890 g male was delivered. His development was normal for the 12-months postnatal follow-up period. The patient remained in a persistent vegetative state. Only 12 cases of severely brain-injured pregnant patients who delivered babies have been reported in English literature. Such patients need special maternal and fetal monitoring. As shown in our patient, successful fetal outcome could be obtained in a mother who suffered from hypovolemic shock and diffuse axonal injury, was treated with numerous medications from 4 weeks' gestation, and survived premature labor at 33 weeks' gestation in a persistent vegetative state. This report represents the longest interval from maternal vegetative state to obstetric delivery. From our case, it would seem that no clear limit exists that restricts the physician's ability to support a severely injured pregnant patient.- - - - - - - - - - ranking = 0.5keywords = shock (Clic here for more details about this article) |
5/26. Recombinant factor viia for control of hemorrhage: early experience in critically ill trauma patients.STUDY OBJECTIVE: To examine our institutional experience with recombinant Factor VIIa (rFVIIa) as a treatment for exsanguinating hemorrhage in critically ill trauma patients. DESIGN: Retrospective case review. SETTING: A specialized trauma and critical care hospital, serving as the quaternary referral center for trauma and surgical shock in the state of maryland. patients: All patients with diffuse coagulopathy and impending exsanguination, given rFVIIa in an effort to control life-threatening hemorrhage. patients were in the intensive care unit (ICU) or operating room (OR) and included both acute admissions and late-stage patients with multiple organ system failure. INTERVENTIONS: patients of interest were those that had received rFVIIa. MEASUREMENTS: Examination of medical records, including pharmacy data, laboratory results, and the institutional trauma registry. MAIN RESULTS: Administration of rFVIIa contributed to successful control of hemorrhage in three of five patients. Failure in two patients was mostly likely due to overwhelming shock and acidosis. CONCLUSIONS: Administration of rFVIIa shows promise in the treatment of exsanguinating hemorrhage. Prospective, controlled clinical trials of this therapy are strongly recommended.- - - - - - - - - - ranking = 1keywords = shock (Clic here for more details about this article) |
6/26. Employing vasopressin as an adjunct vasopressor in uncontrolled traumatic hemorrhagic shock. Three cases and a brief analysis of the literature.Resuscitation of patients in hemorrhagic shock remains one of the most challenging aspects of trauma care. We showed in experimental studies that vasopressin, but not fluid resuscitation, enabled short-term and long-term survival in a porcine model of uncontrolled hemorrhagic shock after penetrating liver trauma. In this case report, we present two cases with temporarily successful cardiopulmonary resuscitation (CPR) using vasopressin and catecholamines in uncontrolled hemorrhagic shock with subsequent cardiac arrest that was refractory to catecholamines and fluid replacement. In a third patient, an infusion of vasopressin was started before cardiac arrest occurred; in this case, we were able to stabilize blood pressure thus allowing further therapy. The patient underwent multiple surgical procedures, developed multi-organ failure, but was finally discharged from the critical care unit without neurological damage.- - - - - - - - - - ranking = 3.5keywords = shock (Clic here for more details about this article) |
7/26. necrosis of the colon as a complication of shock.Colonic necrosis secondary to hypotension and shock in previously healthy, young patients is a rare occurrence with only ten cases reported in the literature. In all but one instance the necrosis was limited to the right colon. Three additional cases of transmural necrosis involving both the right and left colon following a documented episode of shock are reported. Two cases were related to hemorrhagic shock following trauma and the third case followed a drug overdose with associated hypotension. An episode of hypotension was the common denominator in all cases previously reported. The lowest mean blood pressure in the present series was 35 mmHg. A diagnosis of subtotal colonic infarction was made at laparotomy in these three patients two to nine days after the initial hypotensive episode. Pathologic examination of the excised colon revealed transmural necrosis in all three cases with no evidence of a thrombotic or embolic process accounting for the colonic necrosis. The etiology was felt to be a low flow state within the splanchnic circulation. The data suggests that patients who present with a history of prolonged hypotension and shock are at risk for the development of colonic infarction. Successful management involves early diagnosis and resection of the infarcted colon.- - - - - - - - - - ranking = 4keywords = shock (Clic here for more details about this article) |
8/26. The treatment of burned children.Burn shock in infants and children is satisfactorily treated by the initial intravenous administration of balanced hypertonic sodium solutions; monitoring of plasma sodium and/or osmolarity permits necessary adjustment of the sodium concentration of administered fluids. This approach has been safe. Its principal advantage is in minimizing acute gains in body weight, which may be alarming otherwise, especially in children. Clinical and bacteriological data are presented indicating that cerium nitrate-silver sulfadiazine cream is a highly efficient topical antiseptic agent for both major and minor burn wounds and that it has low toxicity. cerium nitrate-silver sulfadiazine cream can be readily employed in any clinical setting.- - - - - - - - - - ranking = 0.5keywords = shock (Clic here for more details about this article) |
9/26. Trauma of occult hydronephrotic kidney.The occult unilateral hydronephrotic kidney is often discovered during the genitourinary evaluation of patients sustaining blunt abdominal trauma. Few cases have been reported documenting the angiographic, computerized tomography (CT), and ultrasound appearances. Two cases are described which demonstrate that relatively minor trauma can precipitate hematuria and hypovolemic shock. angiography demonstrated the bleeding site in both cases and was utilized in conjunction with other parameters of clinical assessment to plan initial management. CT and ultrasound proved to be useful noninvasive diagnostic parameters for baseline and follow-up studies in patients undergoing conservative management. They accurately demonstrated the degree of hydronephrosis, residual renal parenchymal, and resolving hematoma.- - - - - - - - - - ranking = 0.5keywords = shock (Clic here for more details about this article) |
10/26. Principles of treatment and indications for surgery in severe multiple trauma.Despite major advances, pitfalls in diagnosis and emergency treatment influence the survival chances of multitraumatized patients considerably. Diagnosis of traumatic shock cannot be made by blood pressure, pulse rate and shock index. Immediate shock therapy is indicated in all cases with severe trauma of two body regions, combined injury of one body cavity and long bone fractures and in all cases with one major thoracic or pelvic injury. In a consecutive series of 418 multitrauma patients, extremity injuries were present in 90%, severe head injuries in 65%, major thoracic trauma in 50% and abdominal or pelvic injuries in 40%. The most frequent pattern of multitrauma was long bone fractures with associated head trauma and one thoracic, abdominal or pelvic injury. Priorities of treatment are based on a 4-stage-schedule: Stage 1 includes intubation and hyperventilation for cerebral trauma, volume replacement by central venous catheter, emergency x-ray of cervical spine, chest, abdomen, pelvis and diagnostic peritoneal lavage. In 25% of admitted cases, diagnosis of abdominal hemorrhage was missed by the referring surgeon despite hemorrhagic shock, falsely attributed to cerebral trauma. At Stage 2, emergency surgery of internal and external bleeding is indicated. Wide open fractures are stabilized by external fixation. Stage 3 is concerned with stabilization of vital systems and further diagnostic evaluation, its duration varying from 2 hours to 2 days. At Stage 4, internal fixation of fractures and other non-emergency-operations are indicated. Operating time can be reduced considerably by 2 surgical teams operating simultaneously or overlapping. Early shock diagnosis, immediate intubation, ventilator treatment and the "4-stages-schedule" are considered the most successful steps in the management of multitrauma, as well as volume replacement with Fox' hypertonic saline solution and blood constituents instead of colloids. This has reduced mortality due to respiratory failure from 31% to 20%.- - - - - - - - - - ranking = 2.5keywords = shock (Clic here for more details about this article) |
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