Recombinant factor VIIa and the patient with neurologic bleeding: separating fact from fiction.

Notwithstanding its limited Food and Drug Administration-approved indications, rFVIIa has rapidly gained widespread use for the treatment of a variety of hemorrhagic conditions, including intracranial bleeding from spontaneous, traumatic, surgical, and coagulopathic causes. Although it appears that the drug only minimally increases the risk of thromboembolic events, its efficacy remains in question. The idea of finding a universal cure for hemorrhage in a medication bottle remains highly appealing, but enthusiasm for the concept is no replacement for evidence. Neuroscience nurses, who are the interface between patients and rFVIIa, need to balance hope and hype until the facts are all in.

Trauma in pregnancy.

Although serious trauma during pregnancy is uncommon, it remains a major cause of maternal and fetal death and presents a variety of patient care challenges. The anatomic and physiologic changes of pregnancy can affect both the nature of an injury and the body's response to it. Here, the author describes the mechanisms of traumatic injury during pregnancy, discusses the normal changes of pregnancy and their implications in the care of pregnant trauma patients, and offers strategies for assessment and treatment.

5-year survival of geriatric patients following trauma center discharge.

Little is known about the impact of trauma on geriatric injury survivors' life expectancy. Does trauma in older adults influence time to death? What key patient and injury variables can predict 5-year postdischarge survival? This retrospective study used Cox proportional hazards models to quantify seniors' risk for death within 5 years of injury and identify variables associated with life expectancy. The hazard ratio for death in subjects versus matched controls was 6.26. Six patient and injury variables were identified that predicted 5-year vital status in the final multivariate model. There is an ongoing relationship between injury and shortened lifespan in geriatric trauma survivors. This relationship appears to be largely influenced by host factors, rather than by injury variables.

A case of postpartum cerebral venous thrombosis.

Cerebral venous thrombosis, also known as cortical venous, cerebral sinus, cerebral venous sinus, or dural sinus thrombosis, results from clot formation in one of the many outflow tracts of the brain. Obstruction of flow causes venous hypertension, which is responsible for clinical findings associated with this condition. Signs and symptoms of cerebral venous thrombosis include headache, nausea, mental status changes, seizures, and focal neurologic deficits. Although cerebral venous thrombosis can occur at any time during life, women are particularly vulnerable before delivery and during the postpartum period because of the hypercoagulable state that accompanies pregnancy. This case study describes the challenging clinical course of one postpartum patient who developed venous thrombosis of the sagittal sinus.

Variables predicting trauma patient survival following massive transfusion.

INTRODUCTION: The literature contains little information regarding demographic or transfusion-related factors associated with survival following massive blood transfusion in trauma patients. The objective of this study was to describe patient, transfusion, and laboratory variables contributing to survival in this population during the first and second days after arrival at the hospital. A secondary objective was to identify costs associated with massive blood transfusion. METHODS: A 7-year, retrospective review of 13,005 consecutive trauma patient records yielded a sample of 46 who were transfused with > or =50 units of blood products in the first postinjury day. Descriptive statistics were computed to describe the sample, transfusion data, and laboratory values. Logistic regression was used to predict survival using selected patient characteristics, laboratory data, and transfusion characteristics for both the first and second days. RESULTS: Overall survival among this group who received massive transfusion was 63%. No significant differences were found between survivors and nonsurvivors in age, sex, type of trauma, or amount of any of the blood components administered on Day 1. Nonsurvivors had higher Injury Severity Scores and shorter ICU and hospital lengths of stay. Controlling for other variables, only arterial base deficit levels made a significant unique contribution to predicting survival. The volume of blood transfused on Day 2 did not contribute to survival prediction. The average cost of blood transfusion was more than 49,000 US dollars per survivor and 51,000 US dollars per nonsurvivor. CONCLUSION: Defining medical futility based solely on the volume of blood products transfused currently is unjustified. The search for other early indicators of survival in the trauma population must continue.

Pass the salt: indications for and implications of using hypertonic saline.

Sodium is the most abundant extracellular ion. Historically, therapy with hypertonic saline was widely used for a variety of conditions. Currently, there are 3 primary indications for its use in critical care: hyponatremia, volume resuscitation, and brain injury. SIADH and CSW syndrome may require sodium replacement, but most cases of hyponatremia can be managed without administration of hypertonic saline. Studies of use of hypertonic saline in hypovolemia and brain injury are promising, but additional research is needed to better define optimal dosing regimens and to determine the relative risks associated with hypertonic saline versus conventional treatment for the management of patients with head injuries and for volume resuscitation in shock states.

Rhabdomyolysis. Pathophysiology, recognition, and management.

Rhabdomyolysis is a clinical syndrome in which the contents of injured muscle cells leak into the circulation. This leakage results in electrolyte abnormalities, acidosis, clotting disorders, hypovolemia, and acute renal failure. More than 100 conditions, both traumatic and non-traumatic, can lead to rhabdomyolysis. Intervention consists of early detection, treatment of the underlying cause, volume replacement, urinary alkalinization, and aggressive diuresis or hemodialysis. Patients with rhabdomyolysis often require intensive care, and critical care nurses are instrumental in both the early detection and the ongoing management of this life-threatening syndrome.

Pathophysiology and management of abdominal compartment syndrome.

Abdominal compartment syndrome is a potentially lethal condition caused by any event that produces intra-abdominal hypertension; the most common cause is blunt abdominal trauma. Increasing intra-abdominal pressure causes progressive hypoperfusion and ischemia of the intestines and other peritoneal and retroperitoneal structures. Pathophysiological effects include release of cytokines, formation of oxygen free radicals, and decreased cellular production of adenosine triphosphate. These processes may lead to translocation of bacteria from the gut and intestinal edema, predisposing patients to multiorgan dysfunction syndrome. The consequences of abdominal compartment syndrome are profound and affect many vital body systems. Hemodynamic, respiratory, renal, and neurological abnormalities are hallmarks of abdominal compartment syndrome. Medical management consists of urgent decompressive laparotomy. Nursing care involves vigilant monitoring for early detection, including serial measurements of intra-abdominal pressure.