Red tides: Mass casualty and whole blood at sea.

BACKGROUND: The U.S. Navy's casualty-receiving ships provide remote damage control resuscitation platforms to treat injured combatants deployed afloat and ashore. We report a significant mass casualty incident aboard the USS Bataan, and the most warm fresh whole blood (WFWB) transfused at sea for traumatic hemorrhagic shock since the Vietnam War. METHODS: Casualty-receiving ships have robust medical capabilities, including a frozen blood bank with packed red blood cells (pRBC) and fresh frozen plasma (FFP). The blood supply can be augmented with WFWB collected from a "walking blood bank." RESULTS: Following a helicopter crash, six patients were transported by MV-22 Osprey to the USS Bataan. Patient 1 had a pelvic fracture, was managed with a pelvic binder, and received 4 units of pRBC, 2 units of FFP, and 6 units of WFWB. Patient 2, with a comminuted tibia and fibula fracture, underwent lower extremity four-compartment fasciotomy, and received 4 units of WFWB. Patient 3 underwent several procedures, including left anterior thoracotomy, aortic cross-clamping, exploratory laparotomy, small bowel resection, and tracheostomy. He received 8 units of pRBC, 8 units of FFP, and 28 units of WFWB. Patients 4 and 5 had suspected spine injuries and were managed nonoperatively. Patient 6, with open tibia and fibula fractures, underwent lower extremity four-compartment fasciotomy with tibia external fixation and received 1 unit of WFWB. All patients survived aeromedical evacuation to a role 4 medical facility and subsequent transfer to local hospitals. CONCLUSION: Maritime military mass casualty incidents are challenging, but the U.S. Navy's casualty-receiving ships are ready to perform remote damage control resuscitation at sea. Activation of the ship's walking blood bank to transfuse WFWB is essential for hemostatic resuscitations afloat. LEVEL OF EVIDENCE: Study type: case series, level V.

Exercise in the heat: effect of fluid ingestion on blood-brain barrier permeability.

INTRODUCTION: This study examined changes in serum S100beta concentration, a peripheral marker of BBB permeability, in response to exercise in the heat with and without fluid ingestion. METHODS: Eight physically active males completed up to 90 min of intermittent exercise at a power output corresponding to 55% VO2peak in a warm environment (35 degrees C, 56% rh). Trials were completed with (F trial) and without (NF trial) the replacement of sweat losses. During the fluid trial, an aliquot of plain water was ingested at 15-min intervals to match the volume of sweat lost during the previous period of exercise. RESULTS: Exercise time was 80.7 +/- 13.0 min in the NF trial and 85.1 +/- 9.5 min in the F trial (P = 0.107). Fluid ingestion resulted in a smaller rise in core temperature (P = 0.050) and heart rate (P = 0.027) during the latter stages of exercise. Serum S100beta concentrations were 0.08 +/- 0.02 microg.L at rest, increasing to 0.20 +/- 0.06 microg.L at the end of exercise in the NF trial, with this response attenuated by the ingestion of fluid (0.13 +/- 0.03 microg.L; P = 0.046). Both serum sodium concentration (P < 0.001) and serum osmolality (P = 0.003) were significantly lower at the end of exercise in the F trial than in the NF trial. CONCLUSION: The results of this study demonstrate that water ingestion can limit exercise-induced increases in serum S100beta, consistent with the preservation of BBB integrity. It is possible that this response was mediated through the maintenance of lower extracellular osmolality late in exercise, thus potentially limiting the osmotically driven movement of fluid across the BBB.

Alimentary tract surgery in the nonagenarian: elective vs. emergent operations.

The objective of this study was to compare elective with emergent surgery in patients over the age of 90 years. We retrospectively reviewed the records of patients over 90 years of age who underwent alimentary tract surgery between 1994 and 2002 at a community teaching hospital. Of 100 patients (mean age 92 years; range 90 to 98 years), 82 were women and 18 were men. Seventy-three percent were admitted from private homes or assisted-living facilities, and 27% came from a skilled-nursing facility (SNF). Major comorbid conditions existed in 93%. Procedures included right hemicolectomy (22%), adhesiolysis and/or small bowel resection (19%), cholecystectomy (14%), left-sided or sigmoid colectomy (11%), and perineal proctectomy (8%). Overall morbidity and mortality were 36% and 15%, respectively. Postoperative complications included respiratory failure and pneumonia (11%), arrhythmias (9%), delirium (7%), congestive heart failure and myocardial infarction (6%), and urinary complications (4%). Twenty-eight percent of the operations were elective, and 72% were emergent. Morbidity and mortality were higher in the emergent group (41% and 19%, respectively) than in the elective group (26% and 4%, respectively; P=0.04), especially for patients with an emergent surgical problem who came from a nursing home (22%). Average length of stay was 12 +/- 10 days (range 2 to 69 days) with little difference between elective and emergent cases. Sixty-four percent of patients were discharged to skilled-nursing facilities. Alimentary tract surgery can be performed safely in nonagenarians, and they should not be denied surgical care solely because of age.