Circulating sFasL Levels Predict the Severity and Outcome of Burn Injury: A Prospective Observational Study.

BACKGROUND: Severe burn injury activates shock, inflammation, and blood cell system, but inappropriate reactions may lead to adverse outcomes. Soluble Fas ligand (sFasL) participates in apoptosis and inflammatory response. The circulating sFasL levels we investigated in association with the burn severity, shock, inflammation, blood cells, and mortality in patients with severe burns. METHODS: A total of 56 patients with severe burns were recruited. The levels of sFasL and the biomarkers reflecting shock, organ damage, inflammation, and blood cells at 48 h postburn were analyzed. We compared the practical situation of patients that stratified by median sFasL levels and investigated the predictive value of sFasL for mortality. RESULTS: High circulating sFasL levels were associated with the higher degrees of burn index, shock index, lactate, N-terminal probrain natriuretic peptide, total bilirubin, blood urea nitrogen, creatinine, tumor necrosis factor-α, interleukin-1ß, interleukin-8, intercellular adhesion molecule 1, and complement 3, and the lower degrees of oxygenation index, lymphocytes, and platelets. Multiple linear regression analysis showed that the higher tumor necrosis factor-α (P < 0.001) and the lower oxygenation index (P = 0.031) and lymphocytes (P = 0.043) were associated with the higher sFasL. High sFasL (a unit is 50 ng/L) (odds ratio [OR] 5.50 [95% CI 1.04-29.20], P = 0.045) was an independent predictor of increased mortality by multivariate logistic regression analysis. CONCLUSIONS: High circulating sFasL at 48 h postburn in patients with severe burns reflect shock, proinflammatory response, organ damage, and lymphocyte reductions and predict 30-day mortality.

Is restrictive fluid resuscitation beneficial not only for hemorrhagic shock but also for septic shock?: A meta-analysis.

BACKGROUND: Whether to use limited fluid resuscitation (LFR) in patients with hemorrhagic shock or septic shock remains controversial. This research was aimed to assess the pros and cons of utilizing LFR in hemorrhagic shock or septic shock patients. METHODS: PubMed, Cochrane Library, Embase, Web of science, CNKI, VIP, and Wan Fang database searches included for articles published before December 15, 2020. Randomized controlled trials of LFR or adequate fluid resuscitation in hemorrhagic shock or septic shock patients were selected. RESULT: This meta-analysis including 28 randomized controlled trials (RCTs) and registered 3288 patients. The 7 of 27 RCTs were the patients with septic shock. Others were traumatic hemorrhagic shock patients. Comparing LFR or adequate fluid resuscitation in hemorrhagic shock or septic shock patients, the summary odds ratio (OR) was 0.50 (95% confidence interval [CI] 0.42-0.60, P < .00001) for mortality, 0.46 (95% CI 0.31-0.70, P = .0002) for multiple organ dysfunction syndrome (MODS), 0.35 (95% CI 0.25-0.47) for acute respiratory distress syndrome (ARDS), and 0.33 (95% CI 0.20-0.56) for disseminated intravascular coagulation (DIC). CONCLUSION: Limited fluid resuscitation is the benefit of both traumatic hemorrhagic shock patients and septic shock patients.

Fresh whole blood from walking blood banks for patients with traumatic hemorrhagic shock: A systematic review and meta-analysis.

BACKGROUND: Whole blood is optimal for resuscitation of traumatic hemorrhage. Walking Blood Banks provide fresh whole blood (FWB) where conventional blood components or stored, tested whole blood are not readily available. There is an increasing interest in this as an emergency resilience measure for isolated communities and during crises including the coronavirus disease 2019 pandemic. We conducted a systematic review and meta-analysis of the available evidence to inform practice. METHODS: Standard systematic review methodology was used to obtain studies that reported the delivery of FWB (PROSPERO registry CRD42019153849). Studies that only reported whole blood from conventional blood banking were excluded. For outcomes, odds ratios (ORs) and 95% confidence interval (CI) were calculated using random-effects modeling because of high risk of heterogeneity. Quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation system. RESULTS: Twenty-seven studies published from 2006 to 2020 reported >10,000 U of FWB for >3,000 patients (precise values not available for all studies). Evidence for studies was "low" or "very low" except for one study, which was "moderate" in quality. Fresh whole blood patients were more severely injured than non-FWB patients. Overall, survival was equivalent between FWB and non-FWB groups for eight studies that compared these (OR, 1.00 [95% CI, 0.65-1.55]; p = 0.61). However, the highest quality study (matched groups for physiological and injury characteristics) reported an adjusted OR of 0.27 (95% CI, 0.13-0.58) for mortality for the FWB group (p < 0.01). CONCLUSION: Thousands of units of FWB from Walking Blood Banks have been transfused in patients following life-threatening hemorrhage. Survival is equivalent for FWB resuscitation when compared with non-FWB, even when patients were more severely injured. Evidence is scarce and of relative low quality and may underestimate potential adverse events. Whereas Walking Blood Banks may be an attractive resilience measure, caution is still advised. Walking Blood Banks should be subject to prospective evaluation to optimize care and inform policy. LEVEL OF EVIDENCE: Systematic/therapeutic, level 3.

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.

Effect of fibrinogen concentrate administration on early mortality in traumatic hemorrhagic shock: A propensity score analysis.

BACKGROUND: Fibrinogen concentrate is widely used in traumatic hemorrhagic shock despite weak evidence in the literature. The aim of the study was to evaluate the effect of fibrinogen concentrate administration within the first 6 hours on 24-hour all-cause mortality in traumatic hemorrhagic shock using a causal inference approach. METHODS: Observational study from a French multicenter prospective trauma registry was performed. Hemorrhagic shock was defined as transfusion of four or more red blood cell units within the first 6 hours after admission. The confounding variables for the outcome (24-hour all-cause mortality) and treatment allocation (fibrinogen concentrate administration within the first 6 hours) were chosen by a Delphi method. The propensity score was specified with a data-adaptive algorithm and a doubly-robust approach with inverse proportionality of treatment weighting allowed to compute the average treatment effect. Sensitivity analyses were performed. RESULTS: Of 14,336 patients in the registry during the study period, 1,027 in hemorrhagic shock were analyzed (758 receiving fibrinogen concentrate within 6 hours and 269 not receiving fibrinogen concentrate). The average treatment effect, expressed as a risk difference, was -0.031 (95% confidence interval, -0.084 to 0.021). All sensitivity analysis confirmed the results. CONCLUSIONS: Fibrinogen concentrate administration within the first 6 hours of a traumatic hemorrhagic shock did not decrease 24-hour all-cause mortality. LEVEL OF EVIDENCE: Prognostic, level III.

Renal outcomes of intensive care burn patients in an Asian tertiary centre.

INTRODUCTION: Acute kidney injury (AKI) is a frequent complication of severe burn injury and is associated with a high mortality rate of up to 80%. We aimed to establish the incidence, mortality rate, and factors related to mortality in adult patients with severe burn injury and AKI with renal replacement therapy (RRT) in Singapore. METHODS: We performed a retrospective cohort study of severely burned patients who were admitted to the Burns Intensive Care Unit (BICU) at the Singapore General Hospital (SGH) from January 2008 to December 2016. We compared patients with AKI with RRT who survived with those who did not survive. As there were changes in the protocol for burns management after 2013, we also compared patients with AKI with RRT who survived with non-survivors in each of the 2008-2012 and 2013-2016 cohorts. RESULTS: Data of 201 patients were studied. The incidence of AKI with RRT use in severe burn injury was 21.9% and their mortality rate was 50.0%. The non-survivors had significantly higher median burned total body surface area (p = 0.043), earlier AKI (p = 0.046), earlier use of RRT (p = 0.035), lower rate of renal recovery (p = <0.0001), higher rates of adult respiratory distress syndrome (ARDS) (p = 0.005) and shock with vasopressors (p = 0.009) compared to the survivors. The survival rate was 36.8% in the 2008-2012 cohort, but improved to 60.0% in the 2013-2016 cohort. In the 2008-2012 cohort, the non-survivors developed AKI earlier (day 0 admission vs. day 3 admission, p = 0.039), and were initiated on RRT at lower serum creatinine level (173.5 µmol/L vs. 254.0 µmol/L, p = 0.042), when compared to the survivors in this same cohort. On the other hand, there were no significant differences in the renal status and fluid balance parameters between the non-survivors and survivors in the 2013-2016 cohort. CONCLUSIONS: The incidence of AKI with RRT in the Singapore study cohort was high, but their mortality rate was relatively lower compared to other study cohorts. Severity of AKI and use of RRT were associated with poor prognosis. Large scale study is required to further study the risk factors for mortality in this group of patients and establish cause-and-effect relationship.

Risks and benefits of hypotensive resuscitation in patients with traumatic hemorrhagic shock: a meta-analysis.

BACKGROUND: Damage control strategies play an important role in trauma patient management. One such strategy, hypotensive resuscitation, is being increasingly employed. Although several randomized controlled trials have reported its benefits, the mortality benefit of hypotensive resuscitation has not yet been systematically reviewed. OBJECTIVES: To conduct a meta-analysis of the efficacy of hypotensive resuscitation in traumatic hemorrhagic shock patients relative to mortality as the primary outcome, with acute respiratory distress syndrome (ARDS), acute kidney injury (AKI), and multiple organ dysfunction as the secondary outcomes. METHODS: PubMed, Medline-Ovid, Scopus, Science Direct, EMBASE, and CNKI database searches were conducted. An additional search of relevant primary literature and review articles was also performed. Randomized controlled trials and cohort studies reporting the mortality rate associated with hypotensive resuscitation or limited fluid resuscitation were selected. The random-effects model was used to estimate mortality and onset of other complications. RESULTS: Of 2114 studies, 30 were selected for this meta-analysis. A statistically significant decrease in mortality was observed in the hypotensive resuscitation group (risk ratio [RR]: 0.50; 95% confidence interval [CI]: 0.40-0.61). Heterogeneity was observed in the included literature (I2: 27%; degrees of freedom: 23; p = 0.11). Less usage of packed red cell transfusions and fluid resuscitations was also demonstrated. No significant difference between groups was observed for AKI; however, a protective effect was observed relative to both multiple organ dysfunction and ARDS. CONCLUSIONS: This meta-analysis revealed significant benefits of hypotensive resuscitation relative to mortality in traumatic hemorrhagic shock patients. It not only reduced the need for blood transfusions and the incidences of ARDS and multiple organ dysfunction, but it caused a non-significant AKI incidence.

Use of Vasopressor Increases the Risk of Mortality in Traumatic Hemorrhagic Shock: A Nationwide Cohort Study in Japan.

OBJECTIVES: To evaluate the possible association of vasopressor use with mortality in traumatic hemorrhagic shock patients. DESIGN: Retrospective cohort study. SETTING: Traumatic hemorrhagic shock patients at 260 emergency hospitals in Japan between 2004 and 2015. PATIENTS: Three-thousand five-hundred fifty-one traumatic hemorrhagic shock patients who had systolic hypotension (< 90 mm Hg) on arrival at the emergency department and a blood transfusion received within the first 24 hours. INTERVENTIONS: The use of vasopressor for traumatic hemorrhagic shock within the first 24 hours. MEASUREMENTS AND MAIN RESULTS: Among 236,698 trauma patients, 3,551 were included in the study. Overall, 198 of 459 patients (43%) in the vasopressor+ group expired compared with 481 of 3,092 patients (16%) in the vasopressor- group. Use of vasopressor had an odds ratio of 2.172 (95% CI, 1.666-2.833) for in-hospital mortality adjusted for age, gender, year of onset, cause of injury, mechanism of injury, vital signs at the emergency department, Injury Severity Score, use of prehospital IV fluid, and volume of blood transfusion within the first 24 hours. In the propensity score-matched cohort and two subgroup analyses (massive transfusion and survivable injury models), use of vasopressor was associated with higher mortality (odds ratio, 2.168; 95% C, 1.442-3.320), (odds ratio, 2.029; 95% CI, 1.414-2.911; massive transfusion model), and (odds ratio, 1.959; 95% CI, 1.364-2.814; survivable injury model). CONCLUSIONS: Use of vasopressor for traumatic hemorrhagic shock was associated with mortality after controlling for biases (trauma severity; volume of fluid resuscitation).

Does a balanced transfusion ratio of plasma to packed red blood cells improve outcomes in both trauma and surgical patients? A meta-analysis of randomized controlled trials and observational studies.

BACKGROUND: The effect of high transfusion ratios of fresh frozen plasma (FFP): packed red blood cell (RBC) on mortality is still controversial. Observational evidence contradicts a recent randomized controlled trial regarding mortality benefit. This is an updated meta-analysis, including a non-trauma cohort. METHODS: Patients were grouped into high vs. low based on FFP:RBC ratio. Primary outcomes were 24-h and 30-day/in-hospital mortality. Secondary outcomes were acute respiratory distress syndrome and acute lung injury rates. Random model and leave-one-out-analyses were used. RESULTS: In 36 studies, lower ratio showed poorer 24-h and 30-day survival (p < 0.001). In trauma and non-trauma settings, a lower ratio was associated with worse 24-h and 30-day mortality (P < 0.001). A ratio of 1:1.5 provided the largest 24-h and 30-day survival benefit (p < 0.001). The ratio was not associated with ARDS or ALI. CONCLUSIONS: High FFP:RBC ratio confers survival benefits in trauma and non-trauma settings, with the highest survival benefit at 1:1.5.

Blood glucose concentrations in prehospital trauma patients with traumatic shock: A retrospective analysis.

BACKGROUND: Deranged glucose metabolism after moderate to severe trauma with either high or low concentrations of blood glucose is associated with poorer outcome. Data on prehospital blood glucose concentrations and trauma are scarce. OBJECTIVES: The primary aim was to describe the relationship between traumatic shock and prehospital blood glucose concentrations. The secondary aim was to determine the additional predictive value of prehospital blood glucose concentration for traumatic shock when compared with vital parameters alone. DESIGN: Retrospective analysis of the predefined, observational database of a nationwide Helicopter Emergency Medical Service (34 bases). SETTING: Emergency trauma patients treated by Helicopter Emergency Medical Service between 2005 and 2013 were investigated. PATIENTS: All adult trauma patients (≥18 years) with recorded blood glucose concentrations were enrolled. OUTCOMES: Primary outcome: upper and lower thresholds of blood glucose concentration more commonly associated with traumatic shock. Secondary outcome: additional predictive value of prehospital blood glucose concentrations when compared with vital parameters alone. RESULTS: Of 51 936 trauma patients, 20 177 were included. In total, 220 (1.1%) patients died on scene. Hypoglycaemia (blood glucose concentration 2.8 mmol l or less) was observed in 132 (0.7%) patients, hyperglycaemia (blood glucose concentration exceeding 15 mmol l) was observed in 265 patients (1.3%). Blood glucose concentrations more than 10 mmol l (n = 1308 (6.5%)) and 2.8 mmol l or less were more common in patients with traumatic shock (P < 0.0001). The Youden index for traumatic shock ((sensitivity + specificity) - 1) was highest when blood glucose concentration was 3.35 mmol l (P < 0.001) for patients with low blood glucose concentrations and 7.75 mmol l (P < 0.001) for those with high blood glucose concentrations. In logistic regression analysis of patients with spontaneous circulation on scene, prehospital blood glucose concentrations (together with common vital parameters: Glasgow Coma Scale, heart rate, blood pressure, breathing frequency) significantly improved the prediction of traumatic shock in comparison with prediction by common vital parameters alone (P < 0.0001). CONCLUSION: In adult trauma patients, low and high blood glucose concentrations were more common in patients with traumatic shock. Prehospital blood glucose concentration measurements in addition to common vital parameters may help identify patients at risk of traumatic shock.

Efficacy of Uncross-Matched Type O Packed Red Blood Cell Transfusion to Traumatic Shock Patients: a Propensity Score Match Study.

A new blood bank system was established in our trauma bay, which allowed immediate utilization of uncross-matched type O packed red blood cells (UORBCs). We investigated the efficacy of UORBC compared to that of the ABO type-specific packed red blood cells (ABO RBCs) from before the bank was installed. From March 2016 to February 2017, data from trauma patients who received UORBCs in the trauma bay were compared with those of trauma patients who received ABO RBCs from January 2013 to December 2015. Propensity matching was used to overcome retrospective bias. The primary outcome was 24-hour mortality, while the secondary outcomes were in-hospital mortality and intensive care unit (ICU) length of stay (LOS). Data from 252 patients were reviewed and UORBCs were administered to 64 patients. The time to transfusion from emergency room admission was shorter in the UORBC group (11 [7-16] minutes vs. 44 [29-72] minutes, P < 0.001). After propensity matching, 47 patients were included in each group. The 24-hour mortality (4 [8.5%] vs. 9 [13.8%], P = 0.135), in-hospital mortality (14 [29.8%] vs. 18 [38.3%], P = 0.384), and ICU LOS (9 [4-19] days vs. 5 [0-19] days, P = 0.155) did not differ significantly between groups. The utilization of UORBCs resulted in a faster transfusion but did not significantly improve the clinical outcomes in traumatic shock patients in this study. However, the tendency for lower mortality in the UORBC group suggested the need for a large study.

[Polytrauma Management - Treatment of Severely Injured Patients in ER and OR]. / Polytraumamanagement ­ Behandlung des Schwerverletzten in Schockraum und OP.

The adequate treatment of severely injured patients is challenging and can only be successfully executed when it starts at the accident site and is continued in all treatment phases including the early rehabilitation phase. Treatment should be performed by an interdisciplinary team guided by a trauma surgeon in order to adequately manage the severe injuries some of which are life-threatening. Treatment of polytrauma patients is a key task of certified trauma centers and must follow standardized guidelines. For a successful therapy of severely injured patients lifetime training at regular intervals in well-established polytrauma concepts is a mandatory requirement.

Age-related mortality in blunt traumatic hemorrhagic shock: the killers and the life savers.

BACKGROUND: There are sparse data on the association between age and mortality in hemorrhagic shock (HS). We examined this association in this study. MATERIALS AND METHODS: The Glue Grant database was analyzed. Patients aged ≥16 y with blunt traumatic HS were stratified into eight age groups (16-24, 25-34, 35-44, 45-54, 55-64, 65-74, 75-84, and ≥85 y) to identify the mortality inflection point. Subsequently, patients were restratified into young age (16-44 y), middle age (45-64 y), and elderly (≥65 y). Multivariate analysis was used to determine predictors of mortality by group. RESULTS: A total of 1976 patients were included, with mortality of 16%. Mortality by initial age group is as follows: 16-24 (13.0%), 25-34 (11.9%), 35-44 (11.9%), 45-54 (15.6%), 55-64 (15.7%), 65-74 (20.3%), 75-84 (38.2%), and ≥85 y (51.6%), delineating 65 y as the mortality inflection point. Overall, 55% were young, 30% middle age, and 15% elderly. Predictors of mortality in the young include multiple-organ dysfunction score (MODS; odds ratio [OR]: 1.93, confidence interval [CI]: 1.62-2.30), emergency room lactate (OR: 1.14, CI: 1.02-1.27), injury severity score (OR: 1.06, CI: 1.03-1.09), and cardiac arrest (OR: 10.60, CI: 3.05-36.86). Predictors of mortality in the middle age include MODS (OR: 1.38, CI: 1.24-1.53), cardiac arrest (OR: 12.24, CI: 5.38-27.81), craniotomy (OR: 5.62, CI: 1.93-16.37), and thoracotomy (OR: 2.76, CI: 1.28-5.98). In the elderly, predictors of mortality were age (OR: 1.07, CI: 1.02-1.13), MODS (OR: 1.47, CI: 1.26-1.72), laparotomy (OR: 2.04, CI: 1.02-4.08), and cardiac arrest (OR: 11.61, CI: 4.35-30.98). Open fixation of nonfemoral fractures was protective against mortality in all age groups. CONCLUSIONS: In blunt HS, mortality parallels increasing age, with the inflection point at 65 y. MODS and cardiac arrest uniformly predict mortality across all age groups. Craniotomy and thoracotomy are associated with mortality in the middle age, whereas laparotomy is associated with mortality in the elderly.

Allicin ameliorates intraintestinal bacterial translocation after trauma/hemorrhagic shock in rats: The role of mesenteric lymph node dendritic cell.

BACKGROUND: Intestinal dendritic cells play important roles in regulating the function of the intestinal immune barrier and the intestinal bacterial translocation. In this study, we aim to investigate the effects of allicin on the function of mesenteric lymph node-dendritic cells after trauma/hemorrhagic shock. METHODS: One hundred and eight-four Sprague-Dawley rats were randomly assigned into a sham group (n = 46), sham + allicin group (n = 46), trauma/hemorrhagic shock group (n = 46), and trauma/hemorrhagic shock + allicin group (n = 46). Studies were performed on an in vivo model of spontaneously breathing rats with induced trauma/hemorrhagic shock. Allicin was diluted in resuscitation fluid and was administered through the right jugular vein. Flow cytometry was used to determine the expression of CD80, CD86, and major histocompatibility complex II (MHC II) on the surface of mesenteric lymph node-dendritic cells, as well as apoptosis. Intraintestinal bacterial translocation was monitored by using bioluminescent citrobacter. Intestinal permeability tests were conducted by using both FITC-Dextran and Ussing-Chember assay. RESULT: CD80 and MHC-II expression levels were downregulated in the trauma/hemorrhagic shock group compared with the sham and sham + allicin groups; however, the expression was upregulated after allicin treatment. Also, allicin could ameliorate the trauma/hemorrhagic shock-induced increase in early apoptosis of mesenteric lymph node-dendritic cells. A significant increase was observed in the permeability of the intestinal barrier after severe traumatic shock, along with an obvious intraintestinal bacterial translocation to mesenteric lymph node. No difference was noticed in the bacterial translocation in mesenteric lymph node in the trauma/hemorrhagic shock group compared with trauma/hemorrhagic shock + allicin group (P = .589), which indicated allicin could not block bacterial translocation into mesenteric lymph node after trauma/hemorrhagic shock. However, it may increase the capacity of mesenteric lymph node to block intraintestinal bacterial translocation to extraintestinal organs as a statistical difference was noticed in the bacterial translocation in liver, blood, and spleen between trauma/hemorrhagic shock and trauma/hemorrhagic shock + allicin groups (P < .05). CONCLUSION: Trauma/hemorrhagic shock resulted in a decrease of mature mesenteric lymph node-dendritic cells. Allicin treatment could block intraintestinal bacterial translocation through increasing the immunologic barrier function of mesenteric lymph node by modulating dendritic cells maturation.

Pediatric specific shock index accurately identifies severely injured children.

INTRODUCTION: Shock index (SI) (heart rate/systolic blood pressure)>0.9 predicts mortality in adult trauma patients. We hypothesized that age adjusted SI could more accurately predict outcomes in children. METHODS: Retrospective review of children age 4-16 years admitted to two trauma centers between 1/07 and 6/13 following blunt trauma with an injury severity score (ISS)>15 was performed. We evaluated the ability of SI>0.9 at emergency department presentation and elevated shock index, pediatric age adjusted (SIPA) to predict outcomes. SIPA was defined by maximum normal HR and minimum normal SBP by age. Cutoffs included SI>1.22 (age 4-6), >1.0 (7-12), and >0.9 (13-16). RESULTS: Among 543 children, 50% of children had an SI>0.9 but this fell to 28% using age adjusted SI (SIPA). SIPA demonstrated improved discrimination of severe injury relative to SI: ISS>30: 37% vs 26%; blood transfusion within the first 24 hours: 27% vs 20%; Grade III liver/spleen laceration requiring blood transfusion: 41% vs 26%; and in-hospital mortality: 11% vs 7%. CONCLUSION: A pediatric specific shock index (SIPA) more accurately identifies children who are most severely injured, have intraabdominal injury requiring transfusion, and are at highest risk of death when compared to shock index unadjusted for age.

[THE PRINCIPLES OF ORGANIZATION AND TREATMENT FOR SORTING OF WOUNDED PERSONS WITH A COMBAT SURGICAL TRAUMA OF EXTREMITIES ON THE IV LEVEL OF THE MEDICAL CARE PROVISION].

Experience of medical sorting of 434 injured persons with a gun-shot woundings of extremities in 2014-2015 yrs is adduced. The principles of organization and treatment for medical sorting of wounded persons were elaborated. Prognostic intrahospital, diagnostic and evacuation--transport sorting was introduced in wounded persons in the IV level hospital, concerning severity of traumatic shock and prognosis of their survival.

How was the Turin Shroud Man crucified?

As the literature is not exhaustive with reference to the way the Turin Shroud (TS) Man was crucified, and it is not easy to draw significant information from only a "photograph" of a man on a linen sheet, this study tries to add some detail on this issue based on both image processing of high resolution photos of the TS and on experimental tests on arms and legs of human cadavers. With regard to the TS Man hands, a first hypothesis states that the left hand of the TS Man was nailed twice at two different anatomical sites: the midcarpal joint medially to the pisiform between the lunate/pyramidal and capitate/uncinate bones (Destot's space) and the radiocarpal joint between the radio, lunate and scaphoid; also the right hand would have been nailed twice. A second hypothesis, preferred by the authors, states that the hands were nailed only once in the Destot's space with partial lesion of the ulnar nerve and flexion of the metacarpophalangeal joint of the thumbs. With regard to the TS Man feet, the imprint of the sole of the right foot leads to the conclusion that TS Man suffered a dislocation at the ankle just before the nailing. The entrance hole of the nail on the right foot is a few inches from the ankle, and excludes a double nailing. The nail has been driven between the tarsal bones. The TS Man suffered the following tortures during crucifixion: a very serious and widespread causalgia due to total paralysis of the upper right limb (paradoxical causalgia); a nailing of the left wrist with damage to the ulnar nerve; a similar nailing of the right wrist; and a nailing to both feet using one only nail that injured the plantaris medialis nerves. The respiratory limitation was probably not sufficient to cause death by asphyxiation. Also considering the hypovolemia produced by scourging and the many other tortures detectable on the TS, the principal cause of death can be attributed to a myocardial infarction.