Forgot calcium? Admission ionized-calcium in two civilian randomized controlled trials of prehospital plasma for traumatic hemorrhagic shock.

BACKGROUND: Randomized clinical trials (RCTs) support the use of prehospital plasma in traumatic hemorrhagic shock, especially in long transports. The citrate added to plasma binds with calcium, yet most prehospital trauma protocols have no guidelines for calcium replacement. We reviewed the experience of two recent prehospital plasma RCTs regarding admission ionized-calcium (i-Ca) blood levels and its impact on survival. We hypothesized that prehospital plasma is associated with hypocalcemia, which in turn is associated with lower survival. METHODS: We studied patients enrolled in two institutions participating in prehospital plasma RCTs (control, standard of care; experimental, plasma), with i-Ca collected before calcium supplementation. Adults with traumatic hemorrhagic shock (systolic blood pressure ≤70 mm Hg or 71-90 mm Hg + heart rate ≥108 bpm) were eligible. We use generalized linear mixed models with random intercepts and Cox proportional hazards models with robust standard errors to account for clustered data by institution. Hypocalcemia was defined as i-Ca of 1.0 mmol/L or less. RESULTS: Of 160 subjects (76% men), 48% received prehospital plasma (median age, 40 years [interquartile range, 28-53 years]) and 71% suffered blunt trauma (median Injury Severity Score [ISS], 22 [interquartile range, 17-34]). Prehospital plasma and control patients were similar regarding age, sex, ISS, blunt mechanism, and brain injury. Prehospital plasma recipients had significantly higher rates of hypocalcemia compared with controls (53% vs. 36%; adjusted relative risk, 1.48; 95% confidence interval [CI], 1.03-2.12; p = 0.03). Severe hypocalcemia was significantly associated with decreased survival (adjusted hazard ratio, 1.07; 95% CI, 1.02-1.13; p = 0.01) and massive transfusion (adjusted relative risk, 2.70; 95% CI, 1.13-6.46; p = 0.03), after adjustment for confounders (randomization group, age, ISS, and shock index). CONCLUSION: Prehospital plasma in civilian trauma is associated with hypocalcemia, which in turn predicts lower survival and massive transfusion. These data underscore the need for explicit calcium supplementation guidelines in prehospital hemotherapy. LEVEL OF EVIDENCE: Therapeutic, level II.

High-dose vitamin C infusion reduces fluid requirements in the resuscitation of burn-injured sheep.

Fluid resuscitation to maintain adequate tissue perfusion while reducing edema in the severely burned patient remains a challenge. Recent studies suggest that reactive oxygen species generated by thermal injury are involved in edema formation associated with burn. The present study tested the hypothesis that adding a free radical scavenger to the resuscitation fluid would reduce total fluid requirements in the treatment of severe thermal injury. Anesthetized chronically instrumented sheep received a 40% total body surface area full-thickness flame burn. At 1 h after injury, animals were resuscitated with lactated Ringer's (LR, n = 14) as control, LR containing high doses of vitamin C (VC, n = 6), 1000 mOsM hypertonic saline (HS, n = 7), or 1000 HS containing VC (HS/VC, n = 7) in coded bags so that investigators were blinded to the treatment. Fluids were infused at an initial Parkland rate of 10 mL/kg/h, adjusted hourly to restore and maintain urine output at 1 to 2 mL/kg/h. Sheep in the VC or HS/VC group received 250 mg/kg VC in the first 500 mL of LR or HS, and then 15 mg/kg/h thereafter. Hemodynamic variables and indices of antioxidant status were measured. At 48 h postburn, sheep were euthanized, and heart, liver, lung, skeletal muscle, and ileum were evaluated for antioxidant status. All fluid resuscitation regimens were equally effective in restoring cardiac output to near baseline levels; no treatment effects were apparent on arterial pressure or heart rate. VC infusion significantly reduced fluid requirements and, therefore, net fluid balance (fluid in, urine out) by about 30% at 6 h and about 50% at 48 h in comparison with the LR group (P < 0.05). HS and HS/VC reduced fluid requirements by 30% and 65%, respectively, at 6 h, but the volume-sparing effect of HS was not observed after 36 h and that of HS/VC was lost after 12 h. Plasma total antioxidant potential increased about 25-fold (P < 0.05) at 2 and 3 h in response to VC infusion compared with the LR and HS groups, and remained about 5- to 10-fold higher throughout the rest of the study. VC infusion also prevented the 4-fold increase in plasma thiobarbituric acid reactive substances seen in the LR group early after burn (P < 0.05). Tissue antioxidant status was similar between groups. In this sheep burn model, continuous high-dose VC infusion reduced net fluid balance, reduced indices of plasma lipid peroxidation, and maintained overall antioxidant status in comparison with standard-of-care LR treatment.

[Experience of using nutrition therapy in children with multiple and combined trauma in intensive care units].

Caloric and nutrient requirements significantly increase in a pediatric patient with severe injury. This is attributable to catabolism and metabolic features in children cause postoperative complications, increases mortality rates in pediatric surgical patients. This generates the need for early administration of diet therapy using specialized formulas that correct nutrient deficiency. Therefore, the aim of our study was to evaluate the effect of enteral feeding in the early postoperative period: early enteral feeding caused a more rapid increase in the concentrations of transferin and albumin, decreases in C-reactive protein and orosomucoid, and a reduction in the number of the patients who were on early enteral nutrition versus those on a routine postsurgical diet.

Wound shock: a history of its study and treatment by military surgeons.

The treatment of wounds has received considerable attention from the time of the Trojan War. However, it was not until the American Civil War that shock was described as an entity distinct from the wounds themselves and that efforts were directed at more than just treatment of the wound. The need for fluid resuscitation in the treatment of hemorrhagic shock was first recognized in the Spanish American War, as was the association of sepsis with shock. World War I showed the need for blood in the treatment of "wound shock," a lesson that had to be relearned in World War II through bitter experience. Studies in the Korean War described the concept of disseminated intravascular coagulation and multiple organ failure, and the existence of disseminated intravascular coagulation was confirmed by studies in Vietnam. The treatment of hemorrhagic shock is now very effective, but the treatment of traumatic and septic shock remains unsatisfactory.

[Three patients with accidental hypothermia: customized rewarming]. / Drie patiënten met accidentele hypothermie; opwarmen op maat.

Three patients, two men aged 47 and 33 years and a woman aged 33 years, became hypothermic after an accident with body temperatures of 34.5, 26.2 and 23.1 degrees C, respectively. Two of them developed circulatory disorders, for which reanimation was performed. All three patients recovered after active external heating using among other things warmed infusion fluids, a warmed waterbed, continuous arteriovenous rewarming and rewarming with the heart-lung machine. For the treatment to be successful, the type of rewarming selected should be guided by the degree of hypothermia, the circulatory situation and the severity of the accessory injuries.

Cardiac problems associated with burns.

Burns represent a major cause of accidental death in industrialized countries. Before the recognition of the key role of aggressive volume resuscitation in successful management, early mortality was common secondary to burn shock. Salvage of patients with major burns is optimized only if the pathophysiology of burn injury and the time course of hemodynamic derangements is understood. The effects of the neuroendocrine response to burning and the release of mediators from the burn wound on intravascular volume status, ventricular function, peripheral vascular tone, and metabolism must be addressed. In the early postburn period, crystalloid should be administered at a rate prescribed by any of several burn resuscitation formulas. The Parkland formula, providing 4 mL/kg/% burn over the first 24 hours, is the most widely used and has met with consistent success when used as a guideline for resuscitation over the early period of management. Colloid may be added to minimize resuscitation volumes and reduce edema once capillary endothelial competency has been restored. Ongoing resuscitation should be modified based on the clinical response of the patient, primarily the urine output, heart rate, and base deficit. In selected high-risk patients and in those failing resuscitation to clinical goals, invasive hemodynamic monitoring should be used to refine fluid management and identify those patients who may benefit from cardiotonic drugs. The potential contribution of carbon monoxide or cyanide intoxication to hemodynamic instability should be considered in all patients with a compatible history, including a history of inadequate response to treatment. With resolution of the phase of potential burn shock, the increased metabolic needs of the patient and the demands imposed by those needs on the cardiovascular system should be anticipated and supported.

[Blood reinfusion in penetrating gunshot wounds of the abdomen]. / Reinfuziia krovi pri ognestrel'nykh pronikaiushchikh raneniiakh zhivota.

On the basis of literature and their own experience in performing the reinfusion of bacteria-contaminated blood in 20 patients with gunshot penetrating abdominal injuries the authors make a conclusion that in critical cases there are no alternative to application of reinfusion. The article gives clinical examples and contains data concerning the character of lesions. Indications and counter-indications for reinfusion are enclosed.

[The use of the "internal autotransfusion" method in complex shock-control measures at the prehospital stage]. / Primenenie metoda "vnutrennei autotransfuzii" v komplekse protivoshokovykh mer na dogospital'nom étape.

Fifty-three patients with traumatic shock were injected 200-400 ml of a 10% solution of sodium chloride in combination with 100 ml of the 40% solution of glucose. The continuous, for 1-2 h, elevation of arterial pressure, increased minute blood circulation volume, cardiac index, stroke volume were noted. At the same time base deficiency in blood was growing. So, in the last 5 patients the infusion therapy at the prehospital stage was completed by injecting 200 ml of 3% sodium solution and the acid-base state in them was thus leveled. When using the "internal autotransfusion" lethality was reliably less than in patients who were treated by routine (polyglucon, gelatinole) infusion therapy.

[A procedure for infusion-transfusion therapy and autohemodilution in severe trauma and shock (apropos the article by B. N. Salamatin et al., The use of the "internal autotransfusion" method in complex shock-control measures at the prehospital stage)]. / Taktika infuzionno-transfuzionnoi terapii i autogemodiliutsiia pri tiazhelykh travmakh i shoke (po povodu stat'i B. N. Salamatina i soavt. "Primenenie metoda "vnutrennei autotrasfuzii" v komplekse protivoshokovykh mer na dogospital'nom étape").

The infusion of hypertonic solution is thought by the authors to be effective due to its reflectory action for treatment of patients who are in the state of anaphylactic and cardiogenic shock. This method seems to be expedient for massive blood loss under conditions of prehospital medical aid to victims with very low level of arterial pressure, with craniocerebral trauma and critical trauma of the chest.

[The effect of hyperbaric oxygenation on the central hemodynamics and oxygen consumption in severe mechanical trauma]. / Vliianie giperbaricheskoi oksigenatsii na tsentral'nuiu gemodinamiku i potreblenie kisloroda pri tiazheloi mekhanicheskoi travme.

The efficacy of different methods of treatment of severe mechanical trauma with and without hyperbaric oxygenation (HBO) was studied by comparative analysis in experiments on 80 dogs. HBO was found to have a positive influence on the values of central hemodynamics and oxygen consumption in severe traumatic disease. HBO (1-2 atm, 50 min; 4-5 sessions) conducted in the early restorative period increases the survival percentage.

[The efficacy of hyperbaric oxygenation in experimental and hemorrhagic shock]. / Effektivnost' giperbaricheskoi oksigenatsii pri éksperimental'nom gemorragicheskom i travmaticheskom shoke.

The efficacy of hyperbaric oxygenation (HBO, 2 atm, 1 h, altitude chamber "Irtysh-MT") has been studied in acute experiments on 56 adult dogs with hemorrhagic and traumatic shock. It has been established that HBO has a marked therapeutic effect in hemorrhagic shock, especially in its early period, when almost all the animals are saved from death. In the late period of hemorrhagic shock and in the early period of traumatic shock HBO effect was manifested only in insignificant increase in the animals' survival and lifespan. In the late period of traumatic shock toxic effect of hyperbaric O2 application was observed and the majority of animals died before the end of HBO session.

[Immunocorrective therapy of the traumatic syndrome]. / Immunokorrigiruiushchaia terapiia travmaticheskogo sindroma.

The effect of combined application of thymalin and plaferon in the prophylaxis and treatment of traumatic syndrome has been investigated in rats. The survival rate was taken as the criterion of efficiency, the mechanism of the effect obtained being estimated at the level of immunological protective factors. Traumatic shock was induced by Kennon's method in Wistar male rats weighing 200-250 g. Post-traumatic syndrome has been observed within 7 days. The combined application of thymalin and plaferon has increased the survival rate twice within the first 7 days. Immunomodulating effect of the combined application of thymalin and plaferon on the 7th day of traumatic syndrome was most marked at the level of total T-lymphocyte population, theophylline-sensitive T suppressors and lysozyme blood serum activity.