[The concept of small volume resuscitation for preclinical trauma management. Experiences in the Air Rescue Service]

Higher Concentration of Hypertonic Saline Shows Better Recovery Effects on Rabbits with Uncontrolled Hemorrhagic Shock

Background

Our previous study found a novel fluid combination with better resuscitation effects under hypotensive condition at the early stage of uncontrolled hemorrhagic shock (UHS). However, the optimal recovery concentration of hypertonic saline in this fluid combination remains unknown. This experiment aimed to explore the optimal concentration.

Material/Methods

New Zealand white rabbits (n=40) were randomly divided into 5 groups, including a sham-operated group (SO), a shock non-treated group (SNT), a normal saline group (NS), and hypertonic saline groups (4.5% and 7.5%). We established an UHS model and administered various fluid combinations (dose-related sodium chloride solution+crystal-colloidal solution) to the groups followed by monitoring indexes of hemodynamic and renal function, measuring infusion volume and blood loss, and analyzing pathological morphology by hematoxylin and eosin staining.

Results

The hypertonic saline groups showed more stable hemodynamic indexes, reduced blood loss, fewer required infusions, and milder decreases in renal function than those of control groups (SNT and NS groups), and exhibited fewer pathological changes in the heart, lung, kidney, and liver. All indexes in the 4.5% and 7.5% groups were better than those of the NS group, and the hemodynamic indexes in the 7.5% group were more stable than those of the 4.5% group (P<0.05), with reduced blood loss and infusion volume and a milder decrease in renal function.

Conclusions

The novel fluid combination with 7.5% hypertonic saline group had a better recovery effect at the early stage of UHS before hemostasis compared to that of the 4.5% hypertonic saline group. This result may provide guidance for clinical fluid resuscitation.

G-CSF Administration after the Intraosseous Infusion of Hypertonic Hydroxyethyl Starches Accelerating Wound Healing Combined with Hemorrhagic Shock

Objective. To evaluate the therapeutic effects of G-CSF administration after intraosseous (IO) resuscitation in hemorrhagic shock (HS) combined with cutaneous injury rats. Methods. The rats were randomly divided into four groups: (1) HS with resuscitation (blank), (2) HS with resuscitation + G-CSF (G-CSF, 200 μg/kg body weight, subcutaneous injection), (3) HS with resuscitation + normal saline solution injection (normal saline), and (4) HS + G-CSF injection without resuscitation (Unres/G-CSF). To estimate the treatment effects, the vital signs of alteration were first evaluated, and then wound closure rates and homing of MSCs and EPCs to the wound skins and vasculogenesis were measured. Besides, inflammation and vasculogenesis related mRNA expressions were also examined. Results. IO infusion hypertonic hydroxyethyl starch (HHES) exhibited beneficial volume expansion roles and G-CSF administration accelerated wound healing 3 days ahead of other groups under hemorrhagic shock. Circulating and the homing of MSCs and EPCs at wound skins were significantly elevated at 6 h after G-CSF treatment. Inflammation was declined since 3 d while angiogenesis was more obvious in G-CSF treated group on day 9. Conclusions. These results suggested that the synergistical application of HHES and G-CSF has life-saving effects and is beneficial for improving wound healing in HS combined with cutaneous injury rats.

[Fluid resuscitation in hemorrhage]

How fluid resuscitation has to be performed for acute hemorrhage situations is still controversially discussed. Although the forced administration of crystalloids and colloids has been and still is practiced, nowadays there are good arguments that a cautious infusion of crystalloids may be initially sufficient. Saline should no longer be used for fluid resuscitation. The main argument for cautious fluid resuscitation is that no large prospective randomized clinical trials exist which have provided evidence of improved survival when fluid resuscitation is applied in an aggressive manner. The explanation that no positive effect has so far been observed is that fluid resuscitation is thought to boost bleeding by increasing blood pressure and dilutional coagulopathy. Nevertheless, national and international guidelines recommend that fluid resuscitation should be applied at the latest when hemorrhage causes hemodynamic instability. Consideration should be given to the fact that damage control resuscitation per se will neither improve already reduced tissue perfusion nor hemostasis. In acute and possibly rapidly progressing hypovolemic shock, colloids can be used. The third and fourth generations of hydroxyethyl starch (HES) are safe and effective if used correctly and within prescribed limits. If fluid resuscitation is applied with ongoing re-evaluation of the parameters which determine oxygen supply, it should be possible to keep fluid resuscitation restricted without causing undesirable side effects and also to administer a sufficient quantity so that survival of patients is ensured.

[Diagnosis and treatment of abdominal trauma]

Abdominal trauma represents the leading cause of haemorrhagic shock in the severely injured patient and is associated with high mortality and morbidity rates. The trauma surgeon has a central role in the multidisciplinary team addressing the specific diagnostic and therapeutic needs of patients with abdominal trauma. The management of blunt and penetrating abdominal trauma has undergone substantial changes in recent decades. Major innovations have been established in the field of diagnostic imaging and of nonoperative interventions such as angioembolization and endoscopic procedures. Another key development is the introduction of the damage control concept for the care of patients with abdominal trauma. The present manuscript comprises a review of the current management of abdominal trauma with an emphasis on diagnostic and therapeutic innovations.

Clinical implications of immediate or later periportal edema in MS-CT trauma scans: surrogate parameter of intravenous fluid status and venous congestion

Periportal edema (PPE) of the liver in multislice computed tomography (MS-CT) scans that develops immediately (primary PPE [pPPE]) or later (secondary PPE [sPPE]) is not uncommon in severe trauma patients. Although PPE may serve as a marker for blunt abdominal trauma (22-31 % of cases), distinct causes and clinical implications of PPE are unclear. We analyzed the incidence of pPPE and sPPE in 68 MS-CT scans in severe trauma patients (2007-2009). Exclusion criteria were severely burned patients and patients with preexistent liver diseases predisposing to PPE. We divided PPE+ patients into two subpopulations-either initial/primary PPE (pPPE+) or later/secondary PPE (sPPE+). Further patient data were collected and statistically analyzed. PPE+ was found in 27.9 % (n = 19). Females predominated (p = 0.01), and PPE+ patients presented with a significantly better pH at admission (p = 0.008). The total amount of volume resuscitation (1,983 ± 1,155 ml; p = 0.02) and crystalloids (1,117 ± 796 ml; p = 0.006) administered before MS-CT scans was significantly higher in PPE+, whereas the amount of administered colloids (797 ± 640 ml) showed no significant difference in both groups. PPE+ was not associated with further patient data, i.e., trauma mechanism, injury severity, prognosis-relevant factors, adverse clinical events, or mortality. pPPE+ in MS-CT may serve as a surrogate parameter for intravenous volume load and/or venous congestion, and sPPE+ may also indicate venous congestion and right heart failure after severe trauma. In severe trauma patients with pPPE+/sPPE+ in MS-CT scans, causes of PPE relating to intravenous fluid overload and/or venous congestion should be excluded or treated.