[Differential surgical treatment of victims with damage to the small and large intestines in a closed abdominal injury combined, depending on the prediction of traumatic disease course and morphological changes of the intestinal wall].

Use of differentiated surgical approach to the management of surgical treatment, depending on the degree of violation of systemic hemodynamics, the timing and volume of surgical procedures, depending on the prognosis of traumatic disease course of cardiac index, interventions in the small and large intestine depending on morphological changes of the intestinal wall by cardiac and stroke indexes, put method extra-enteric anastomosis in patients with damage to the small intestine and colon combined with closed abdominal injury permitted to reduce the rate of postoperative complications from 22.2 to 10.1%, mortality at 2.1 times in shock period (from 19.3 to 9.2%) and the overall mortality from 33.3 to 21.1%.

[Stages of diagnosis and surgical treatment for combined bladder injuries].

62 case histories of patients with bladder injuries who were admitted in the Department of Urology and Emergency Surgery of the Republican Scientific Center of Emergency Medicine (RRCEM) from 2001 to 2010 were retrospectively analyzed. 15 (24.2%) patients with hematuria or urethremorrhagia were admitted in the emergency room within an hour after the injury onset. Three (4.8%) patients were hospitalized in the period 1-3 h since injury onset, 12 (19.3%) patients since 3-6 hours, 5 (8.1%) - since 6 to 12 h, 16 (25 8%) patients - since 12 to 24 hours, and 11 (17.7%) patients - after 24 hours. Concomitant injury of the bladder with fractures of the pelvic occurred in 21 (33.8%) cases. At the time of admission in the emergency room, I-II degree traumatic shock was diagnosed in 37 (60%) of patients, III-IV degree traumatic shock - in 11 (17,7%). All 62 patients had a complete rupture of the bladder, 37 (59.6%) of patients had intraperitoneal rupture, 23 (37.1%) - extraperitoneal rupture, and only 2 (3.3%) - mixed rupture. Strict adherence to the RRCEM algorithm of diagnosis and treatment of patients with bladder injuries have substantially improved the efficiency of complex of medical and diagnostic measures and improved the outcomes of this group of patients - mortality was 12.9%.

An Assessment of Research Priorities to Dampen the Pendulum Swing of Burn Resuscitation.

On June 17 to 18, 2019, the American Burn Association, in conjunction with Underwriters Laboratories, convened a group of experts on burn resuscitation in Washington, DC. The goal of the meeting was to identify and discuss novel research and strategies to optimize the process of burn resuscitation. Patients who sustain a large thermal injury (involving >20% of the total body surface area [TBSA]) face a sequence of challenges, beginning with burn shock. Over the last century, research has helped elucidate much of the underlying pathophysiology of burn shock, which places multiple organ systems at risk of damage or dysfunction. These studies advanced the understanding of the need for fluids for resuscitation. The resultant practice of judicious and timely infusion of crystalloids has improved mortality after major thermal injury. However, much remains unclear about how to further improve and customize resuscitation practice to limit the morbidities associated with edema and volume overload. Herein, we review the history and pathophysiology of shock following thermal injury, and propose some of the priorities for resuscitation research. Recommendations include: studying the utility of alternative endpoints to resuscitation, reexamining plasma as a primary or adjunctive resuscitation fluid, and applying information about inflammation and endotheliopathy to target the underlying causes of burn shock. Undoubtedly, these future research efforts will require a concerted effort from the burn and research communities.

Bilateral vagotomy inhibits apnea and attenuates other physiological responses after blunt chest trauma.

BACKGROUND: Behind armor blunt trauma (BABT) is defined as the nonpenetrating injury resulting from a ballistic impact on body armor. Some of the kinetic energy is transferred to the body, causing internal injuries and, occasionally, death. The aim of this study was to investigate if apnea and other pathophysiological effects after BABT is a vagally mediated reflex. METHODS: Sixteen anesthetized pigs wearing body armor, of which five were vagotomized, were shot with a standard 7.62 mm assault rifle. These animals were compared with control animals (n = 8), shot with blank ammunition. We performed bilateral vagotomy before the shot and assessed the outcome on the apnea period, respiration, circulation, and brain function. Animals were monitored during a 2-hour period after the shot. RESULTS: Nonvagotomized animals had a mean apnea period of 22 (6-44) seconds. This group also showed a significant decrease in oxygen saturation compared with control animals. Furthermore, electroencephalogram-changes were more pronounced in nonvagotomized animals. In contrast, vagotomized animals were protected from apnea and showed only a minor decrease in oxygen saturation. All exposed animals showed impaired circulation, and postmortem examination revealed a pulmonary contusion. CONCLUSION: This study shows that apnea after BABT is a vagally mediated reflex that can be inhibited by bilateral vagotomy. Our results indicate that the initial apnea period is an important factor for hypoxia after BABT. Supported ventilation should begin immediately if the affected person is unconscious and suffers from apnea. It should continue until the neurologic paralysis disappears and sufficient spontaneous breathing begins.

Noninvasive hemodynamic monitoring for combat casualties.

The aims of this study were to develop and to test a noninvasive hemodynamic monitoring system that could be applied to combat casualties to supplement conventional vital signs, to use an advanced information system to predict outcomes, and to evaluate the relative effectiveness of various therapies with instant feedback information during acute emergency conditions. In a university-run inner city public hospital, we evaluated 1,000 consecutively monitored trauma patients in the initial resuscitation period, beginning shortly after admission to the emergency department. In addition to conventional vital signs, we used noninvasive monitoring devices (cardiac index by bioimpedance with blood pressure and heart rate to measure cardiac function, arterial hemoglobin oxygen saturation by pulse oximetry to reflect changes in pulmonary function, and tissue oxygenation by transcutaneous oxygen tension indexed to fractional inspired oxygen concentration and carbon dioxide tension to evaluate tissue perfusion). The cardiac index, mean arterial pressure, pulse oximetry (arterial hemoglobin oxygen saturation), and transcutaneous oxygen tension/fractional inspired oxygen concentration were significantly higher in survivors, whereas the heart rate and carbon dioxide tension were higher in nonsurvivors. The calculated survival probability was a useful outcome predictor that also served as a measure of severity of illness. The rate of misclassification of survival probability was 13.5% in the series as a whole but only 6% for patients without severe head injuries and brain death. Application of noninvasive hemodynamic monitoring to acute emergency trauma patients in the emergency department is feasible, safe, and inexpensive and provides accurate hemodynamic patterns in continuous, on-line, real-time, graphical displays of the status of cardiac, pulmonary, and tissue perfusion functions. Combined with an information system, this approach provided an early outcome predictor and evaluated, with an objective individualized method, the relative efficacy of alternative therapies for specific patients.

A snapshot of circulation failure following acute traumatic injury: The expansion of computed tomography beyond injury diagnosis.

OBJECTIVE: CT scans with a flat Inferior Vena Cava (IVC) suggest hypovolemia, and the presence of shock bowel implies hypoperfusion. The purpose of this study is to correlate injury severity, resuscitation needs, and clinical outcomes with CT indices of hypovolemia and hypoperfusion. DESIGN: Retrospective cohort study. SETTING: Level II trauma centre in Central California. PATIENTS: Adult patients imaged with abdominal and pelvic CT scans, from January 2010-January 2011. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Circulatory derangements on CT scans were defined as an IVC (AP) diameter measurement of <9 mm, flat IVC (FIVC), hypovolemia. The presence of small intestine hypoperfusion was shock bowel (SB). The absence of these findings was a normal CT scan (NCT). Comparisons of acid-base status, fluids, morbidity and mortality were made based on CT findings. Subgroups were: FIVC (n=20), FIVC+SB (n=19), SB (n=4) only versus normal CT scans, NCT (n=47). RESULTS: Overall ISS was 19 (SD) 14. The lowest ISS was in NCT 14 (SD) 10 and there was an incremental increase in ISS based on circulatory derangements, p=0.001. ICU admission was lowest in NCT and highest in the presence of hyovolemia and hypoperfusion, p=0.03. Similarly ED crystalloid requirements and the activation of a massive transfusion protocol (MTP), was lowest in NCT group and gradually increased significantly as hypovolemia and hypoperfusion was demonstrated on CT scans. Additional parameters such as metabolic acidosis, nosocomial infections and mortality were associated with acute CT findings of circulatory failure. CONCLUSIONS: Hypovolemia and hypoperfusion, markers of abnormal circulation, were demonstrated on CT scans for trauma evaluation. The presence of these findings alone or in combination showed strong correlation with high injury severity, and the need for aggressive resuscitation.

[Results of treatment of polytrauma in pregnant women].

There was studied the traumatic disease course in 11 pregnant women with different variants of severe combined thoracic and abdominal trauma, constituting 1.6% of total number of injured persons, suffering polytrauma. Polytrauma have had caused severe course of traumatic disease in majority of pregnant women. In the early postshock period the complications had occurred in 90.9% of injured persons. Antenatal death of fetus was noted in 81.8% of pregnant women with polytrauma. All pregnant women after polytrauma are alive.

Protection against burn, tourniquet and endotoxin shock by histamine, 5-hydroxytryptamine and 5-hydroxytryptamine derivatives.

1. 5-Hydroxytryptamine (5-HT), tryptamine, 5-methyltryptamine, 5-methoxytryptamine, N-methyltryptamine, 5-hydroxy-N,N-dimethyltryptamine, and histamine markedly protect mice subjected to burn, tourniquet and endotoxin shock. All of these compounds protect when given 30 min before the production of shock, but not when administered afterwards.2. The above compounds, as well as purines and purine derivatives have a similar chemical structure. Protection requires the compounds to contain a 5-membered ring with one unsubstituted N atom and a side chain with a basic N atom three atoms from the ring.3. All other biological amines tested without this chemical structure did not protect.4. Since the simplest compounds containing all the prerequisites for protection is histamine, this compound may play the key role in protection, for both 5-HT and purines release histamine from tissues.5. Protective doses of 5-HT and histamine prevent swelling of the injured area after tourniquet trauma and produce an increased bleeding volume and lower haematocrit value after burning. These actions of the drugs on the circulation may account for the increased survival after thermal trauma.

Protective effects of KW-3635, a novel thromboxane A2 antagonist, in murine traumatic shock.

Pentobarbital anesthetized rats subjected to Noble-Collip drum trauma developed a shock state characterized by marked hypotension, increases in plasma cathepsin D (9.6-fold), free amino-nitrogen (4.0-fold), and myocardial depressant factor (5.2-fold) activities, and a survival time of 1.90 +/- 0.23 h. Following the induction of traumatic shock, plasma thromboxane B2 (TxB2) concentrations significantly increased from 3.12 +/- 0.68 to 6.78 +/- 0.27 pmol/ml. Treatment with the thromboxane receptor antagonist KW-3635 10 min post-trauma (2 mg/kg + 2 mg/kg per h, i.v.) prolonged survival time to 3.30 +/- 0.39 h (P less than 0.01) and attenuated the accumulation of cathepsin D compared to untreated trauma rats (6.6 +/- 1.1 and 13.6 +/- 1.3 U/ml, P less than 0.01), free amino-nitrogen (6.4 +/- 1.1 and 14.3 +/- 1.2 U/ml, P less than 0.01), and myocardial depressant factor (45 +/- 5 and 94 +/- 13 U/ml, P less than 0.02). However, KW-3635 did not prevent the increase in plasma TxB2 concentration, suggesting a lack of thromboxane synthetase inhibitory activity of this drug. The beneficial effects of thromboxane A2 (TxA2) antagonism in the present study are highly significant, and consistent with the concept that TxA2 is involved in the pathogenesis of traumatic shock.

Medical anti-shock trousers (pneumatic anti-shock garments) for circulatory support in patients with trauma.

BACKGROUND: Medical antishock trousers (MAST) have been used to increase venous return to the heart until definitive care could be given. This, combined with compression of blood vessels, is believed to cause the movement of blood from the lower body to the brain, heart and lungs. However, the equipment is expensive, and may have adverse effects. OBJECTIVES: To quantify the effect on mortality and morbidity of the use of medical anti-shock trousers (MAST)/ pneumatic anti-shock garments (PASG) in patients following trauma. SEARCH STRATEGY: Trials were identified by searches of the Cochrane Injuries Group Trials Register, the Cochrane Controlled Trials Register, MEDLINE, EMBASE, BIDS ISI Service and Science Citation Index. References in relevant papers identified were followed up. A citation analysis of references to randomised controlled trials was conducted using the Science Citation Index. Authors of identified trials were contacted and asked about any other trials that may have been conducted, whether published or unpublished. SELECTION CRITERIA: Randomised and quasi-randomised trials of MAST/PASG in patients following trauma (excluding fractures of the extremities in which MAST/PASG may be used as a splint). DATA COLLECTION AND ANALYSIS: Data were extracted independently by two reviewers. Data were collected on mortality, duration of hospitalisation and ICU stay, and quality of allocation concealment. MAIN RESULTS: Two trials were identified that met the inclusion criteria. These trials included 1202 randomised patients in total; however, data for only 1075 of these were available. The relative risk of death with MAST was 1.13 (95% CI 0.97 to 1.32). Duration of hospitalisation and of intensive care unit stay was longer in the MAST treated group. The weighted mean difference in the length of intensive care unit stay was 1.7 days (95% CI 0.33 to 2.98). REVIEWER'S CONCLUSIONS: There is no evidence to suggest that MAST/PASG application reduces mortality, length of hospitalisation or length of ICU stay in trauma patients and it is possible that it may increase these. These data do not support the continued use of MAST/PASG in the situation described. However, it should be recognised that, due to the poor quality of the trials, conclusions should be drawn with caution.

Efficacy of two leukotriene antagonists in rat traumatic shock.

The effects of CGP 33304 and CGP 35949 were studied in standardized model of traumatic shock. Both drugs are dual leukotriene receptor antagonists and phospholipase A2 inhibiting agents. Pentobarbital anesthetized rats (35 kg/mg) subjected to Noble-Collip drum trauma were characterized by a 128 +/- 16 min survival time and a 4-fold increase in plasma myocardial depressant factor (MDF) activity. CGP 33304 and CGP 35949 both significantly (p less than 0.01) attenuated the accumulation of MDF activity in the plasma (24 +/- 3 and 29 +/- 3 U/ml, respectively, vs. 57 +/- 5 U/ml in the trauma and vehicle group). A significant improval in survival time (p less than 0.05) was observed in the CGP 33304 treated group (182 +/- 23 min) and the CGP 35949 treated group (204 +/- 33 min). Both drugs exhibited significant anti-proteolytic activity in pancreatic homogenates. CGP 33304 and CGP 35949 appear to attenuate MDF production, probably secondary to their anti-proteolytic effect and the improved state of the splanchnic circulation. Both drugs also may prevent hypoxia secondary to leukotriene induced bronchoconstriction in shock states. CGP 33304 and CGP 35949 may, therefore, prove to be useful therapeutic agents in acute ischemic disorders including traumatic shock.

Repeated large-dose haptoglobin therapy in an extensively burned patient: case report.

The case of a 24-year-old man who sustained a 100% body surface area burn and inhalation injury is presented. Hemoglobinuria reappeared 2 hours after haptoglobin was first administered. In addition to individualized fluid resuscitation and plasma administration, a large dose of haptoglobin was repeatedly administered while we monitored for occult blood in the centrifuged urine. As a result, postburn shock and acute renal failure were prevented.

KBSIM/FLUIDTHERAPY: a system for optimized design of fluid resuscitation in trauma.

An application of the KBSIM (Knowledge-Based SIMulation) system to the improved design of fluid resuscitation is described. The system integrates knowledge from three domains, viz. the pathophysiology of traumatized patients represented in a quantitative biodynamic model, the heuristics of fluid resuscitation of such patients as represented in 'production rules', and some 'metaknowledge' reflected in the design of a multi-window user interface. This technique of combining numerical simulation with symbolic reasoning has obvious advantages during the design process and in training, by giving the user a possibility to evaluate his measures by direct feedback from the system. This feature of the system to assist in evaluation of alternative resuscitation procedures should also be useful as a means for decision support.

Trends in burn resuscitation: shifting the focus from fluids to adequate endpoint monitoring, edema control, and adjuvant therapies.

Bum shock is a complex process involving a series of intertwined physiologic responses to injury that require more rigorous intervention than simply a change in fluid tonicity, fluid composition, or fluid resuscitation volume. Controversy ensues over monitoring techniques and resuscitation goals, in part because the identification of true markers of perfusion is clouded by intradependence of endpoints on other metabolic processes. The persistence of cellular hypoperfusion in patients who have been deemed adequately resuscitated by global indices supports the growing realization that failure of conventional endpoint-monitoring strategies to detect compensated bum shock can lead to significant organ injury from SIRS or MODS. Current endpoints should be interpreted in the aggregate, because none have yet been demonstrated to reflect tissue perfusion status independently and accurately. Numerous technologically advanced endpoints to predict patient outcome, which may be useful in determining futility of treatment or end-of-life decisions, are now available. Still lack-ing, however, is a reliable tool proven to improve outcome that can guide bum shock resuscitation therapies successfully. Exciting new research in tissue oxygenation and perfusion has revealed that damaging mediator cascades and irreversible microvascular changes may preclude complete resolution of bum shock solely through restoration of oxygen delivery. Because bum patients now frequently survive the early resuscitation phase. the focus should be on controlling derangements in oxygen use and correcting occult hypoperfusion to reduce later adverse patient outcomes from SIRS, sepsis, and MODS. Bum-specific research on resuscitation endpoints and monitoring strategies lags behind research in other patient populations. Present standards and monitoring guidelines for bum shock resuscitation should be critically evaluated and based on true, scientifically validated data rather than on observational studies or personal beliefs. Thus the continuing challenge for clinicians and researchers:burn centers must collaborate to perform large, multi-center studies to evaluate critically and to prove resuscitation endpoints and therapies. Future technologies targeted at microcirculatory perfusion and cellular oxygenation offer an exciting promise for less invasive, easily accessible, more accurate endpoints and treatments for bum shock resuscitation.

The treatment of burns in children.

As a cause of accidental death in childhood, burns are exceeded only by motor car injuries and drownings. The mortality has been reduced substantially in recent years, but very many children must still carry scars both physical and emotional for the rest of their lives from burning accidents, many of which were preventable.

Intervention with nitric oxide synthase inhibitors for traumatic shock in rats.

OBJECTIVE: To evaluate the effects of a selective inhibitor of inducible nitric oxide synthase (iNOS) aminoguanidine (AG) and a non-selective inhibitor of nitric oxide synthase (NOS) N(G)-nitro-L-arginine methylester (L-NAME) on traumatic shock in rats. METHODS: Animal models of traumatic shock were established in 44 Sprague-Dawley rats following fractures in both femur shafts and subsequent depletion until the mean arterial pressure in the femoral artery dropped to 35 to 45 mmHg(4.67-6.00 kPa). Hypotension was maintained for 30 min before the collected blood was infused back into the rats supplemented with Ringer's solution of the same volume. The rat models were then randomly divided into 3 groups, namely traumatic shock group (n=10), AG group (which was subdivided into AGI, AGII, and AGIII groups, each consisting of 8 rats and receiving 2, 8, and 60 mg/kg x b.w AG infusion respectively during resuscitation), and L-NAME group (with 8 mg/kg x b.w L-NAME infusion during resuscitation, n=10). Plasma NO levels were determined before and after shock, immediately after resuscitation and 0.5, 2, 4 h after resuscitation, and the survival rates within 24 h were recorded with tissue samples of the lung, liver, kidney and intestine obtained 24 h after shock for microscopic examination. RESULTS: Plasma NO level was seen to increase markedly after traumatic shock in the rat models. In the 3 AG groups, the elevated NO levels following the shock were obviously reduced after resuscitation with less tissue damages and higher survival rates, as compared with the other 2 groups. The best protective effect against traumatic shock was observed in AGIII group. In spite of obvious plasma NO level-lowering effect after resuscitation, L-NAME exhibited little efficacy in alleviating the tissue damages in the organs and hence failed to improve the survival rate of the rats. CONCLUSIONS: NO plays an important role in the pathological process of traumatic shock, and the application of AG may improve the condition. L-NAME can decrease plasma NO level after resuscitation, but fail to improve the outcome of traumatic shock in rats.

[Coagulation disorders following severe trauma: surgeon's role in prevention]. / Turbe della coagulazione nel trauma severo: il ruolo del chirurgo nella prevenzione.

INTRODUCTION: Severe trauma must be considered a "systemic disease" that could lead to severe systemic complications. PHYSIOPATHOLOGIC IMPLICATIONS: Coagulation disorders are present in most trauma patients as hemorrhagic disorder, thrombosis, or like in DIC, with both coexistent phenomenon. Trauma determine the activations of intrinsic and extrinsic coagulation pathways, and of platelets. Intrinsic pathway activation induce a pro-coagulant function and the activation of fibrinolytic system. Both system activation explain low incidence of deep venous thrombosis. Post-traumatic activation of extrinsic coagulation lead to thrombin and fibrin production. In trauma patients platelets activation is related to endothelial damage, exposition of collagen, interaction with PAF and presence of microorganisms. Post-traumatic DIC is characterized by procoagulant factors activation, with intravascular deposit of fibrin and thrombosis, and by hemorrhagic disorders due to consumption of platelet and procoagulant factors. Lower levels of antithrombin III, in trauma patients, are strictly related to severity of damage and shock. Coagulation disorders related to sepsis, that often complicate trauma, are added to those determined by trauma, with a negative synergic effect. Medical treatment with massive infusion of colloid and crystalloid solution, and fluid, and massive transfusion of plasma and red blood cells can determine dilutional thrombocytopenia, reduced activity of coagulation factors and reduced haemostatic activity of RBC due to excessive haemodilution--Hct <20%. PREVENTION STRATEGY: To avoid post-traumatic coagulation disorders is important to prevent sepsis, thrombocytopenia and reduced activity of coagulation factors and of RBC, as well as prevent and immediately treat shock. The early use of high dose antithrombin concentrate, is important to prevent DIC and MOFS, and administer subcutaneous or intravenous heparin, in absence of hemorrhagic disorders that contraindicate its use.

[Surgical treatment of open pneumothorax]. / Khirurgicheskoe lechenie otkrytogo pnevmotoraksa.

An analysis of clinical observations shows the successful treatment of most patients with open pneumothorax to be possible under conditions of urgent suturing of the wound defect of the chest, drainage of the pleural cavity and antishock therapy. Thoracotomy is necessary for a small amount of the patients.

[Early respiratory support in anti-shock therapy of children with severe thermal trauma]. / Ranniaia respiratornaia podderzhka v protivoshokovoi terapii u detei s tiazheloi termicheskoi travmoi.

Search for effective method for decreasing the mortality of children with severe thermal injuries and approaches to preventing and treating multiorgan dysfunction in severe thermal injury is a pressing problem of reanimatology. The majority of scientists consider disorders in the ventilation-perfusion function of the lungs the main factor in the pathogenesis of burn shock. Lung injury is most often the first manifestation of multiple organ dysfunction. The depth of disorders in the gas exchange function of the lungs clearly correlates with the severity of burn injury and the terms of the beginning of respiratory support. The severity of burn shock, preclinical diagnosis of acute respiratory distress syndrome and disseminated intravascular blood coagulation, depth of hemodynamic disorders and disorders in the oxygen transporting system can serve as a criterion of the compensatory stress and be an indication for active respiratory therapy. Comparison of the main and control groups demonstrated the efficiency of early respiratory therapy in children with severe burns, because such therapy normalizes the blood oxygen transporting function and hemodynamic parameters sooner and with less strain for the compensatory potential of the organism.

[Treatment of injuries of the heart and pericardium in a regional hospital]. / Lechenie ranenii serdtsa i perikarda v raionnoi bol'nitse.

Wounds of the heart and pericardium were observed in 19 patients. Four patients died. The main causes of death were acute blood loss, shock, tamponade of the heart. Urgent operations are indicated to all the patients with wounds in the cardiac area. The outcome of the surgery is dependent on the rapid and efficient operation and adequate blood supply.