Post-Traumatic Intracranial Pseudoaneurysm Presenting as Epistaxis.

Background: Epistaxis is a frequent presenting complaint in the Emergency Department (ED). Roughly 60% of the population will suffer from epistaxis in their lifetime. The most common causes of epistaxis include nose picking, facial trauma, foreign bodies, and coagulopathies. There are other causes that are much less common, such as intracranial pseudoaneurysms. There are multiple causes that precipitate intracranial pseudoaneurysm formation, with head trauma accounting for less than 1% of inciting events. Case Report: A 24-year-old female with history of traumatic brain injury with associated skull fractures due to a gunshot wound to the head 6 months prior presented to the ED in hemorrhagic shock secondary to epistaxis. After stabilization with the administration of blood products, Computed Tomography with Angiography (CTA) imaging of the head and neck was obtained and revealed a 3.1 × 2.2 × 2.5 cm pseudoaneurysm of the cavernous portion of the right internal carotid artery penetrating through the base of the skull into the ethmoidal sinus. The patient was taken for formal angiography by interventional radiology-and a partially thrombosed daughter sac of the initial aneurysm was identified and believed to be the source of the hemorrhage. The aneurysm was successfully coiled and occluded using ONYX embolization. Postoperatively, the patient returned to her baseline mental status without any acute complaints. The patient was discharged back to her nursing home 2 days later with a 3-week follow-up CTA revealing persistent occlusion of the aneurysm and a patent internal carotid artery. Conclusion: Awareness and consideration of intracranial vascular etiology for common complaints in the emergency room, such as Epistaxis, especially in patients with any history of head injury/trauma, known intracranial aneurysms or prosthetic devices from prior surgery may help guide decision-making in managing critically ill patients.

[Risk factors for acute respiratory distress syndrome in patients with traumatic hemorrhagic shock].

OBJECTIVE: To investigate the risk factors of acute respiratory distress syndrome (ARDS) after traumatic hemorrhagic shock. METHODS: This was a retrospective cohort study of 314 patients with traumatic hemorrhagic shock at Trauma Medicine Center, Peking University People's Hospital from December 2012 to August 2021, including 152 male patients and 162 female patients, with a median age of 63.00 (49.75-82.00) years. The demographic data, past medical history, injury assessment, vital signs, laboratory examination and other indicators of these patients during hospitalization were recorded. These patients were divided into two groups, ARDS group (n=89) and non-ARDS group (n=225) according to whether there was ARDS within 7 d of admission. Risk factors for ARDS were identified using Logistic regression. The C-statistic expressed as a percentage [area under curve (AUC) of the receiver operating characteristic (ROC) curve] was used to assess the discrimination of the model. RESULTS: The incidence of ARDS after traumatic hemorrhagic shock was 28.34%. Finally, Logistic regression model showed that the independent risk factors of ARDS after traumatic hemorrhagic shock included male, history of coronary heart disease, high acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score, road traffic accident and elevated troponin Ⅰ. The OR and 95% confidence intervals (CI) were 4.01 (95%CI: 1.75-9.20), 5.22 (95%CI: 1.29-21.08), 1.07 (95%CI: 1.02-1.57), 2.53 (95%CI: 1.21-5.28), and 1.26 (95%CI: 1.02-1.57), respectively; the P values were 0.001, 0.020, 0.009, 0.014, and 0.034, respectively. The ROC curve was used to analyze the value of each risk factor in predicting ARDS. It was found that the AUC for predicting ARDS after traumatic hemorrhagic shock was 0.59 (95%CI: 0.51-0.68) for male, 0.55 (95%CI: 0.46-0.64) for history of coronary heart disease, 0.65 (95%CI: 0.57-0.73) for APACHE Ⅱ score, 0.58 (95%CI: 0.50-0.67) for road traffic accident, and 0.73 (95%CI: 0.66-0.80) for elevated troponin Ⅰ, with an overall predictive value of 0.81 (95%CI: 0.74-0.88). CONCLUSION: The incidence of ARDS in patients with traumatic hemorrhagic shock is high, and male, history of coronary heart disease, high APACHE Ⅱ score, road traffic accident and elevated troponin Ⅰ are independent risk factors for ARDS after traumatic hemorrhagic shock. Timely monitoring these indicators is conducive to early detection and treatment of ARDS after traumatic hemorrhagic shock.

Local carbachol application induces oral microvascular recruitment and improves gastric tissue oxygenation during hemorrhagic shock in dogs.

Introduction: Hemorrhagic shock is characterized by derangements of the gastrointestinal microcirculation. Topical therapy with nitroglycerine or iloprost improves gastric tissue oxygenation but not regional perfusion, probably due to precapillary adrenergic innervation. Therefore, this study was designed to investigate the local effect of the parasympathomimetic carbachol alone and in combination with either nitroglycerine or iloprost on gastric and oral microcirculation during hemorrhagic shock. Methods: In a cross-over design five female foxhounds were repeatedly randomized into six experimental groups. Carbachol, or carbachol in combination with either nitroglycerine or iloprost were applied topically to the oral and gastric mucosa. Saline, nitroglycerine, or iloprost application alone served as control groups. Then, a fixed-volume hemorrhage was induced by arterial blood withdrawal followed by blood retransfusion after 1h of shock. Gastric and oral microcirculation was determined using reflectance spectrophotometry and laser Doppler flowmetry. Oral microcirculation was visualized with videomicroscopy. Statistics: 2-way-ANOVA for repeated measurements and Bonferroni post-hoc analysis (mean ± SEM; p < 0.05). Results: The induction of hemorrhage led to a decrease of gastric and oral tissue oxygenation, that was ameliorated by local carbachol and nitroglycerine application at the gastric mucosa. The sole use of local iloprost did not improve gastric tissue oxygenation but could be supplemented by local carbachol treatment. Adding carbachol to nitroglycerine did not further increase gastric tissue oxygenation. Gastric microvascular blood flow remained unchanged in all experimental groups. Oral microvascular blood flow, microvascular flow index and total vessel density decreased during shock. Local carbachol supply improved oral vessel density during shock and oral microvascular flow index in the late course of hemorrhage. Conclusion: The specific effect of shifting the autonomous balance by local carbachol treatment on microcirculatory variables varies between parts of the gastrointestinal tract. Contrary to our expectations, the improvement of gastric tissue oxygenation by local carbachol or nitroglycerine application was not related to increased microvascular perfusion. When carbachol is used in combination with local vasodilators, the additional effect on gastric tissue oxygenation depends on the specific drug combination. Therefore, modulation of tissue oxygen consumption, mitochondrial function or alterations in regional blood flow distribution should be investigated.

Preferential whole blood transfusion during the early resuscitation period is associated with decreased mortality and transfusion requirements in traumatically injured patients.

Introduction: Whole blood (WB) transfusion represents a promising resuscitation strategy for trauma patients. However, a paucity of data surrounding the optimal incorporation of WB into resuscitation strategies persists. We hypothesized that traumatically injured patients who received a greater proportion of WB compared with blood product components during their resuscitative efforts would have improved early mortality outcomes and decreased transfusion requirements compared with those who received a greater proportion of blood product components. Methods: Retrospective review from our Level 1 trauma center of trauma patients during their initial resuscitation (2019-2022) was performed. WB to packed red blood cell ratios (WB:RBC) were assigned to patients based on their respective blood product resuscitation at 1, 2, 3, and 24 hours from presentation. Multivariable regression models were constructed to assess the relationship of WB:RBC to 4 and 24-hour mortality, and 24-hour transfusion requirements. Results: 390 patients were evaluated (79% male, median age of 33 years old, 48% penetrating injury rate, and a median Injury Severity Score of 27). Overall mortality at 4 hours was 9%, while 24-hour mortality was 12%. A significantly decreased 4-hour mortality was demonstrated in patients who displayed a WB:RBC≥1 at 1 hour (5.9% vs. 12.3%; OR 0.17, p=0.015), 2 hours (5.5% vs. 13%; OR 0.16, p=0.019), and 3 hours (5.5% vs. 13%, OR 0.18, p<0.01), while a decreased 24-hour mortality was displayed in those with a WB:RBC≥1 at 24 hours (7.9% vs. 14.6%, OR 0.21, p=0.01). Overall 24-hour transfusion requirements were significantly decreased within the WB:RBC≥1 cohort (12.1 units vs. 24.4 units, p<0.01). Conclusion: Preferential WB transfusion compared with a balanced transfusion strategy during the early resuscitative period was associated with a lower 4 and 24-hour mortality, as well as decreased 24-hour transfusion requirements, in trauma patients. Future prospective studies are warranted to determine the optimal use of WB in trauma. Level of evidence: Level III/therapeutic.

Anesthesia Approach to Managing Severe Hemorrhagic Shock and Anemia With Non-transfusion Alternatives in a Practicing Jehovah's Witness: A Case Report.

Traumatic hemorrhagic shock is a common yet life-threatening occurrence across the United States and is typically managed with blood transfusions as the standard of care. However, providers caring for a Jehovah's Witness patient who refuses transfusions due to religious reasons face unique ethical challenges in upholding evidence-based shock resuscitation protocols while respecting the patient's autonomy and faith-based stance that strictly prohibits blood products. We present a complex clinical case of a 46-year-old Jehovah's Witness who developed severe hemorrhagic shock, partial amputation, and critical anemia after a traumatic 40-mile-per-hour motorcycle collision resulting in comminuted fractures and arterial disruption. Despite receiving emergent blood transfusions initially, further transfusions were declined once his identity as a practicing Jehovah's Witness was disclosed. His hemoglobin plunged to dangerously low levels of 4.6 g/dL before stabilizing to 5.3 g/dL with pharmaceutical alternatives including intravenous iron, high-dose erythropoietin, and phlebotomy minimization. Respecting patient convictions while delivering effective evidence-based shock management created significant ethical conflicts given the proven efficacy of blood transfusions. However, this complex case demonstrates that through meticulous medical and surgical care coordinated by a multi-disciplinary team applying customized non-transfusion techniques, traumatic hemorrhagic shock and life-threatening anemia can still achieve favorable outcomes without relying on transfusions when respecting faith-based refusal of blood products.

Resuscitation and Care in the Trauma Bay.

Start balanced resuscitation early (pre-hospital if possible), either in the form of whole blood or 1:1:1 ratio. Minimize resuscitation with crystalloid to minimize patient morbidity and mortality. Trauma-induced coagulopathy can be largely avoided with the use of balanced resuscitation, permissive hypotension, and minimized time to hemostasis. Using protocolized "triggers" for massive and ultramassive transfusion will assist in minimizing delays in transfusion of products, achieving balanced ratios, and avoiding trauma induced coagulopathy. Once "audible" bleeding has been addressed, further blood product resuscitation and adjunct replacement should be guided by viscoelastic testing. Early transfusion of whole blood can reduce patient morbidity, mortality, decreases donor exposure, and reduces nursing logistics during transfusions. Adjuncts to resuscitation should be guided by laboratory testing and carefully developed, institution-specific guidelines. These include empiric calcium replacement, tranexamic acid (or other anti-fibrinolytics), and fibrinogen supplementation.

Trauma Bay Evaluation and Resuscitative Decision-Making.

The reader of this article will now have the ability to reflect on all aspects of high-quality trauma bay care, from resuscitation to diagnosis and leadership to debriefing. Although there is no replacement for experience, both clinically and in a simulation environment, trauma clinicians are encouraged to make use of this article both as a primer at the beginning of a trauma rotation and a reference text to revisit after difficult cases in the trauma bay. Also, periods of reflection seem appropriate in the busy but, of course, rewarding career in trauma care.

Identifying Trigger Cues for Hospital Blood Transfusions Based on Ensemble Learning Methods.

Background: Traumatic shock is the leading cause of preventable death with most patients dying within the first 6 hours. This underscores the importance of prehospital interventions, and growing evidence suggests prehospital transfusion improves survival. Optimizing transfusion triggers in the prehospital setting is key to improving outcomes for patients in hemorrhagic shock. Our objective was to identify factors associated with early in-hospital transfusion requirements available to prehospital clinicians in the field to develop a simple algorithm for prehospital transfusion, particularly for patients with occult shock. Methods: We included trauma patients transported by a single critical care transport service to a level I trauma center between 2012 and 2019. We used logistic regression, Fast and Frugal Trees (FFTs), and Bayesian analysis to identify factors associated with early in-hospital blood transfusion as a potential trigger for prehospital transfusion. Results: We included 2,157 patients transported from the scene or emergency department (ED) of whom 207 (9.60%) required blood transfusion within 4 hours of admission. The mean age was 47 (IQR = 28-62) and 1,480 (68.6%) patients were male. From 13 clinically relevant factors for early hospital transfusions, four were incorporated into the FFT in following order: 1) SBP, 2) prehospital lactate concentration, 3) Shock Index, 4) AIS of chest (sensitivity = 0.81, specificity = 0.71). The chosen thresholds were similar to conventional ones. Using conventional thresholds resulted in lower model sensitivity. Consistently, prehospital lactate was among most decisive factors of hospital transfusions identified by Bayesian analysis (OR = 2.31; 95% CI 1.55-3.37). Conclusions: Using an ensemble of frequentist statistics, Bayesian analysis and machine learning, we developed a simple, clinically relevant, prehospital algorithm to help identify patients requiring transfusion within 4 hours of hospital arrival.

Mortality in hypotensive combat casualties who require emergent laparotomy in the forward deployed environment.

INTRODUCTION: Mortality rates among hypotensive civilian patients requiring emergent laparotomy exceed 40%. Damage control (DCR) principles were incorporated into the military's Clinical Practice Guidelines (CPG) in 2008. We examined combat casualties requiring emergent laparotomy to characterize how mortality rates compare to hypotensive civilian trauma patients. METHODS: The DoD Trauma Registry (2004-2020) was queried for adults who underwent combat laparotomy. Patients who were hypotensive were compared to normotensive patients. Mortality was the outcome of interest. Mortality rates before (2004-2007) and after (2009-2020) DCR CPG implementation were analyzed. RESULTS: 1051 patients were studied. Overall mortality was 6.5% for normotensive casualties and 28.7% for hypotensive casualties. Mortality decreased in normotensive patients but remained unchanged in hypotensive patients following the implementation of the DCR CPG. CONCLUSION: Hypotensive combat casualties undergoing emergent laparotomy demonstrated a mortality rate of 29.5%. Despite many advances, mortality rates remain high in hypotensive patients requiring emergent laparotomy.

The regulatory effects of serum catecholamines and endothelial cells in pig hemorrhagic shock and fluid resuscitation models.

Background: Acute blood loss not only leads to systemic compensatory response, but also the induced changes in vascular endothelial function.These pathological changes may have potential compensatory significance for maintaining organ perfusion and fluid resuscitation. Objective: To understand trauma-induced endotheliopathy and their compensatory roles in acute hemorrhage, a porcine model of hemorrhagic shock (HS) was used to evaluate changes in vascular endothelial factors and catecholamine levels at different time points from shock to fluid resuscitation. Methods: HS was induced in female pigs by rapid bleeding via the arterial sheath. Hemodynamic monitoring was performed using a pulse index continuous cardiac output (PiCCO) system in HS and fluid resuscitation. Femoral vein blood samples were collected at baseline and 40% mean arterial pressure (MAP, shock), MAP recovery, and 30 min, 1 h, and 2 h after recovery. Serum levels of catecholamine and Angiopoietin-1 (Ang-1), Angiopoietin-2 (Ang-2), Tie-2, Eselectin, intracellular adhesion molecule-1 (ICAM-1), soluble thrombomodulin (sTM), and Syndecan-1 (SDC-1) were evaluated using enzyme-linked immunosorbent assay (ELISA). Results: Serum catecholamine levels were significantly higher in the shock than in the baseline state. Ang-1 and Ang-2 are endothelial growth factors secreted with distinct roles. Ang-1 stabilizes the endothelium and inhibits vascular leakage, and Ang-2 has the opposite effect. The ratio of Ang-2/Ang-1 was significantly higher in the shock state than in the baseline state; however, the Ang-1/Tie-2 ratio was comparable between the two states. This suggests that changes in vascular permeability may mainly depend on the upregulation of Ang-2 function. Serum levels of E-selectin, ICAM-1, sTM, and SDC-1 were significantly higher in the shock state than in the baseline state. After the MAP was restored to the baseline state, the levels of E-selectin, and SDC-1 remained higher compared with the baseline state until 1 h after MAP recovery. Conclusions: serum levels of catecholamines and vascular endothelial markers increased transiently under HS, promoting a compensatory response of the circulatory system to acute bleeding. This may be one of the potential theoretical basis for restrictive fluid resuscitation.

Icariin mitigates anxiety-like behaviors induced by hemorrhagic shock and resuscitation via inhibiting of astrocytic activation.

BACKGROUND: Abnormal activation of astrocytes in the amygdala contributes to anxiety after hemorrhagic shock and resuscitation (HSR). Nuclear factor κ-light-chain-enhancer of activated B cells (NF-κB)-associated epigenetic reprogramming of astrocytic activation is crucial to anxiety. A bioactive monomer derived from Epimedium icariin (ICA) has been reported to modulate NF-κB signaling and astrocytic activation. PURPOSE: The present study aimed to investigate the effects of ICA on post-HSR anxiety disorders and its potential mechanism of action. METHODS: We first induced HSR in mice through a bleeding and re-transfusion model and selectively inhibited and activated astrocytes in the amygdala using chemogenetics. Then, ICA (40 mg/kg) was administered by oral gavage once daily for 21 days. Behavioral, electrophysiological, and pathological changes were assessed after HSR using the light-dark transition test, elevated plus maze, recording of local field potential (LFP), and immunofluorescence assays. RESULTS: Exposure to HSR reduced the duration of the light chamber and attenuated open-arm entries. Moreover, HSR exposure increased the theta oscillation power in the amygdala and upregulated NF-κB p65, H3K27ac, and H3K4me3 expression. Contrarily, chemogenetic inhibition of astrocytes significantly reversed these changes. Chemogenetic inhibition in astrocytes was simulated by ICA, but chemogenetic activation of astrocytes blocked the neuroprotective effects of ICA. CONCLUSION: ICA mitigated anxiety-like behaviors induced by HSR in mice via inhibiting astrocytic activation, which is possibly associated with NF-κB-induced epigenetic reprogramming.

The effect of Channa striata, Moringa oleifera, and Curcuma xanthorrhiza extract on accelerating recovery in a ventilated patient with hemorrhagic shock grade 3 due to prolonged retained placenta: a case report.

BACKGROUND: Most of critically ventilated patients with severe hemorrhagic shock experience metabolic acidosis, hypoalbuminemia, electrolyte imbalance, and increased production of free radical. Channa striata has a high content of albumin, an essential binding protein that contributes to homeostasis, and when combined with Moringa oleifera and Curcuma xanthorrhiza, they act as powerful antioxidants. Administration of C. striata, M. oleifera, and C. xanthorrhiza extract orally may benefit patient with hemodynamic issues, including significant blood loss. CASE REPORT: A 40-year-old Indonesian woman came to emergency department with decreased consciousness resulting from hemorrhagic shock grade 3 due to prolonged placenta retention for 10 days after delivery of her third child. She had an emergency hysterectomy and was sent to the intensive care unit with a hemoglobin level of 4.2 gr/dL, despite already receiving two bags of packed red blood cells during operation, and she continued with four more bags within her first day in the intensive care unit. The patient was ventilated, was supported by vasopressors, and had a low albumin level of 2.1 gr/dL. Her hemodynamic profile was difficult to stabilize, with persistent gastric residue and periodic urine output less than 1 cc/kg/hour, thereby slowing the ventilator and vasopressor weaning process. Oral supplementation of C. striata, M. oleifera, and C. xanthorrhiza was given in the second day divided in three doses every 6 hours. After the second dose, gastric residue started to subside and disappeared after the third dose. The patient's condition improved in the next 24 hours; she was extubated and discharged from the hospital in the fourth day. CONCLUSION: This is the first case report describing the effect of C. striata, M. oleifera, and C. xanthorrhiza extract in a patient with severe hemorrhagic shock due to a prolonged placenta. Accelerated recovery showed the possibility benefit of C. striata, M. oleifera, and C. xanthorrhiza extract in stabilizing oncotic pressure, neutralizing free radicals, and preventing further damage in hypoxic cells.

Penetrating injury to the left ventricle caused by attempted suicide-a case report.

Penetrating cardiac injuries are rare but are one of the most urgent emergencies because they require early intervention in order to prevent death. The mortality rate of such injuries, including pre-hospitalization deaths, goes up to 90%. The most commonly injured heart chamber is the right ventricle since it takes over half of the anterior thoracic wall. The left ventricle is injured less often, but these patients usually have worse prognoses and higher mortality rates because such injuries lead to hemodynamic instability faster. We present a unique case of a suicide attempt in which the patient stabbed himself with a knife, penetrated the left ventricle, and survived even though he transected the second diagonal branch of the left anterior descending coronary artery and pulled the knife out of his chest.

Determining the manner of death in victims in drug-induced psychosis: a case of an atypical head stab wound.

This case report presents a rare case of an atypical head stab wound suffered by a drug addict and inflicted with a screwdriver during drug-induced psychosis. It describes the diagnostic and treatment procedures in the hospital and the findings of the subsequent autopsy. It also analyzes the review of the interpretation of the CT scans made upon admission and the subsequent treatment by an independent medical review panel, which revealed signs of medical mismanagement. Therefore, it also discusses the legal consequences that the case may have involved for the attending physicians in addition to the consequences for the suspected perpetrator. The report raises many issues encountered in the case in terms of the clinical treatment and forensic determination of the manner of death in cases of injuries caused by sharp instruments and highlights the importance of comprehensive evaluation of the circumstantial evidence together with the clinical or autopsy findings, since such evidence may sometimes be overlooked in clinical practice.

Impact of Immunopathy and Coagulopathy on Multi-Organ Failure and Mortality in a Lethal Porcine Model of Controlled and Uncontrolled Hemorrhage.

Uncontrolled hemorrhage is a major preventable cause of death in patients with trauma. However, the majority of large animal models of hemorrhage have utilized controlled hemorrhage rather than uncontrolled hemorrhage to investigate the impact of immunopathy and coagulopathy on multi-organ failure (MOF) and mortality. This study evaluates these alterations in a severe porcine controlled and uncontrolled hemorrhagic shock (HS) model. Anesthetized female swine underwent controlled hemorrhage and uncontrolled hemorrhage by partial splenic resection followed with or without lactated Ringer solution (LR) or Voluven® resuscitation. Swine were surveyed 6 h after completion of splenic hemorrhage or until death. Blood chemistry, physiologic variables, systemic and tissue levels of complement proteins and cytokines, coagulation parameters, organ function, and damage were recorded and assessed. HS resulted in systemic and local complement activation, cytokine release, hypocoagulopathy, metabolic acidosis, MOF, and no animal survival. Resuscitation with LR and Voluven® after HS improved hemodynamic parameters (MAP and SI), metabolic acidosis, hyperkalemia, and survival but resulted in increased complement activation and worse coagulopathy. Compared with the LR group, the animals with hemorrhagic shock treated with Voluven® had worse dilutional anemia, coagulopathy, renal and hepatic dysfunction, increased myocardial complement activation and renal damage, and decreased survival rate. Hemorrhagic shock triggers early immunopathy and coagulopathy and appears associated with MOF and death. This study indicates that immunopathy and coagulopathy are therapeutic targets that may be addressed with a high-impact adjunctive treatment to conventional resuscitation.

When Minutes Matter: A Comparison of Whole Blood Collection Techniques.

BACKGROUND: Fast and reliable blood collection is critical to emergency walking blood banks (WBB) because mortality significantly declines when blood is quickly administered to a warfighter with hemorrhagic shock. Phlebotomy for WBB is accomplished via either the "straight stick" (SS) or "ruggedized lock" (RL) method. SS comprises a 16-gauge phlebotomy needle connected to a blood collection bag via tubing. The RL device collects blood through the same apparatus, but has a capped, intravenous (IV) catheter between the needle and the donor's arm. This is the first study to compare these two methods in battlefield-relevant metrics. METHODS: Military first responders and licensed medical providers (N=86) were trained in SS and RL as part of fresh whole blood training exercises. Outcomes included venipuncture success rates, time to IV access, blood collection times, total time, and user preferences, using a within-subjects crossover design. Data were analyzed using ANOVA and nonparametric statistics at p<0.05. RESULTS: SS outperformed RL in first venipuncture success rates (76% vs. 64%, p=0.07), IV access times (448 [standard error of the mean; SE 23] vs. 558 [SE 31] s, p<0.01), and blood collection bag fill times (573 [SE 48] vs. 703 [SE 44] s, p<0.05), resulting in an approximate 3.5-minute faster time overall. Survey data were mixed, with users perceiving SS as simpler and faster, but RL as more reliable and secure. CONCLUSION: SS is optimal when timely collection is imperative, while RL may be preferable when device stability or replacing the collection bag is a consideration.

Evaluation of hemorrhagic shock and fluid resuscitation in pigs using handless Doppler carotid artery ultrasound.

OBJECTIVE: This study aimed to utilize a hemorrhagic shock pig model to compare two hemodynamic monitoring methods, pulse index continuous cardiac output (PiCCO) and spectral carotid artery Doppler ultrasound (CDU). Additionally, we sought to explore the feasibility of employing CDU as a non-invasive hemodynamic monitoring tool in the context of hemorrhagic shock and fluid resuscitation. DESIGN: Animal experiments. SETTING AND SUBJECTS: Female pigs were selected, and hemorrhagic shock was induced by rapid bleeding through an arterial sheath. INTERVENTIONS: Hemodynamic monitoring was conducted using both PiCCO and CDU during episodes of hemorrhagic shock and fluid resuscitation. MEASUREMENTS AND MAIN RESULTS: Among the 10 female pigs studied, CDU measurements revealed a significant decrease in carotid velocity time integral (cVTI) compared to baseline values under shock conditions. During the resuscitation phase, after the mean arterial pressure (MAP) returned to its baseline level, there was no significant difference between cVTI and baseline values. A similar trend was observed for carotid peak velocity (cPV). The corrected flow time (FTc) exhibited a significant difference only at the time of shock compared to baseline values. In comparison to PiCCO, there was a significant correlation between cVTI and MAP (r = 0.616, P < 0.001), stroke volume (SV) (r = 0.821, P < 0.001), and cardiac index (CI) (r = 0.698, P < 0.001). The carotid Doppler shock index (cDSI) displayed negative correlations with MAP (r = - 0.593, P < 0.001), SV (r = - 0.761, P < 0.001), and CI (r = - 0.548, P < 0.001), while showing a positive correlation with the shock index (SI) (r = 0.647, P < 0.001). CONCLUSIONS: Compared to PiCCO, CDU monitoring can reliably reflect the volume status of hemorrhagic shock and fluid resuscitation. CDU offers the advantages of being non-invasive, providing real-time data, and being operationally straightforward. These characteristics make it a valuable tool for assessing and managing hemorrhagic shock, especially in resource-limited settings.

Hemostatic effect of fibrinogen concentrate on traumatic massive hemorrhage: a propensity score matching study.

Background: Fibrinogen concentrate (FC) can be administered during massive transfusions to manage trauma-induced coagulopathy. However, its effectiveness in survival remains inconclusive due to scarce high-level evidence. This study aimed to investigate the hemostatic effects of FC regarding mortality in massive hemorrhage caused by trauma. Methods: This retrospective study analyzed 839 patients who received massive transfusions (red blood cells (RBCs) ≥5 units in 4 hours or ≥10 units in 24 hours) at a level I trauma center between 2015 and 2022. Patients who were transferred to other hospitals or were deceased upon arrival, suffered or died from severe brain injury, and were aged 15 years or less were excluded (n=334). 1:2 propensity score matching was performed to compare the 'FC (+)' group who had received FC in 24 hours (n=68) with those who had not ('FC (-)', n=437). The primary outcome was mortality, and the secondary outcomes included transfusion volume. Results: The variables for matching included vital signs, injury characteristics, prehospital time, implementation of resuscitative endovascular balloon occlusion of the aorta, and blood gas analysis results. The administration of FC did not significantly reduce or predict mortality (in-hospital, 24 hours, 48 hours, or 7 days). The FC (-) group received more units of RBC (25.69 units vs. 16.71 units, p<0.001, standardized mean difference [SMD] 0.595), fresh frozen plasma (16.79 units vs. 12.91 units, p=0.023, SMD 0.321), and platelets (8.76 units vs. 5.46 units, p=0.002, SMD 0.446) than the FC (+) group. Conclusion: The use of FC did not show survival benefits but reduced transfusion requirements in traumatic massive hemorrhages, highlighting a need for future investigations. In the future, individualized goal-directed transfusion with FC may play a significant role in treating massive bleeding. Level of evidence: IV, retrospective study having more than one negative criterion.