Recent advances in topical agents for prehospital haemostasis

The prehospital treatment of severe extremity bleeding has remained unchanged for years and relies on compression with absorbent gauze dressings. Advances in haemostasis technology have identified several new methods of improving bleeding control. These are examined with a view to possible inclusion in a new prehospital dressing aimed at reducing the degree of exsanguination and associated mortality and morbidity from a major extremity injury.

Preliminary studies of sulphur mustard-induced lung injury in the terminally anesthetized pig: exposure system and methodology

ABSTRACT Although normally regarded as a vesicant, inhalation of sulphur mustard (HD) vapor can cause life-threatening lung injury for which there is no specific treatment. Novel therapies for HD-induced lung injury are best investigated in an in vivo model that allows monitoring of a range of physiological variables. HD vapor was generated using two customized thermostatically controlled glass flasks in parallel. The vapor was passed into a carrier flow of air (81 L. min(-1)) and down a length of glass exposure tube (1.75 m). A pig was connected to the midpoint of the exposure tube via a polytetrafluoroethylene-lined endotracheal tube, Fleisch pneumotachograph, and sample port. HD vapor concentrations (40-122.8 mg. m(-3)) up-and downstream of the point of exposure were obtained by sampling onto Porapak absorption tubes with subsequent analysis by gas chromatography-flame photometric detection. Real-time estimates of vapor concentration were determined using a photo-ionization detector. Lung function indices (respiratory volumes, lung compliance, and airway resistance) were measured online throughout. Trial runs with methylsalicylate (MS) and animal exposures with HD demonstrated that the exposure system rapidly reached the desired concentration within 1 min and maintained stable output throughout exposure, and that the MS/HD concentration decayed rapidly to zero when switched off. A system is described that allows reproducible exposure of HD vapor to the lung of anesthetized white pigs. The system has proved to be robust and reliable and will be a valuable tool in assessing potential future therapies against HD-induced lung injury in the pig. Crown Copyright (c) 2007 Dstl.

The treatment of sulphur mustard burns with laser debridement

The chemical warfare agent, sulphur mustard (SM), is a potent blistering agent in man. Skin exposure can produce partial-thickness burns which take up to three months to heal. The aim of this study was to investigate the use of early laser ablation as a means of accelerating this exceptionally slow rate of healing. Four circular partial-thickness SM burns were induced on the dorsum of nine large white pigs (under general anaesthesia). At 72 h post-exposure, three burns per animal were ablated with a single pass of an UltraPulse 5000C CO(2) laser, at a fluence of 5-6 J cm(-2). All the burns were dressed with silver sulphadiazine and a semi-occlusive dressing. At one, two and three weeks post-surgery three animals were culled and all lesions excised for histological analysis. Burn depth was confirmed and measurements of the radii of regenerative epithelium were performed allowing the area of the zone of re-epithelialisation in each lesion to be calculated. Laser-treated lesions showed a significant increase (350%) in healing rates compared to controls (p<0.005). At two weeks, the laser-treated sites were 95% healed in comparison with control sites (28% healed). These data suggest that laser ablation may be effective in the treatment of partial-thickness SM-induced skin injury.

Effects of inhaled nitric oxide on the anesthetized, mechanically ventilated, large white pig

Inhalation of nitric oxide (NO) results in selective pulmonary vasodilation, which may be beneficial in the treatment of acute lung injury. However, NO has toxic effects, and it is important to monitor the effects and fate of inhaled NO. Under intravenous general anesthesia, large white female pigs were instrumented, ventilated with intermittent positive pressure ventilation (IPPV, FiO(2) 0.3; TV 10 ml kg(-1); RR 20 bpm; PEEP 3 cm H(2)O) and monitored for 24 h. Following a period of stabilization, groups were exposed to air (control), or to 10, 40, or 80 ppm NO, delivered via the endotracheal tube in each inspiratory breath. At regular intervals throughout the 24-h period, physiological measurements and arterial blood, plasma, and urine samples were collected. Inhalation of NO acted specifically on the pulmonary vasculature, as no alterations in systemic blood pressure were observed. Administration of NO at 80 ppm resulted in a decreased mean pulmonary artery pressure, decreased pulmonary wedge pressure, and increased methemoglobin and plasma/urine nitrate levels. At post mortem, congestion of the alveolar capillary network was noted in this group. In addition increases in plasma/urine nitrate levels were also observed in the 40 ppm group. In contrast, no significant alterations were observed in the 10 ppm group, compared to the control group. Therefore, 10 ppm inhaled NO is a dose that induced no pathological changes in normal healthy lungs and may be of use as a therapeutic adjunct in the management of acute lung injury.

Pathophysiological responses following phosgene exposure in the anaesthetized pig

This study aimed to develop a reproducible model of phosgene-induced lung injury in the pig to facilitate the future development of therapeutic strategies. Ten female young adult large white pigs were used. Following induction of anaesthesia using a halothane/oxygen/nitrous oxide mixture, arterial and venous catheters were inserted together with a pulmonary artery thermodilution catheter, and a suprapubic urinary catheter by laparotomy. Anaesthesia was maintained throughout the experiment by intravenous infusion of ketamine, midazolam and alfentanil. On completion of surgery the animals were allowed to equilibrate for 1 h and then were divided into two groups. Group 1 (n = 5) was exposed to phosgene for 10 min (mean Ct = 2443 +/- 35 mg min m(-3)) while spontaneously breathing, whereas control animals (Group 2 n = 5) were exposed to air. At 30 min post-exposure, anaesthesia was deepened in order to allow the initiation of intermittent positive pressure ventilation and the animals were monitored for up to 24 h. Cardiovascular and respiratory parameters were monitored every 30 min and blood samples were taken for arterial and mixed venous blood gas analysis and clinical chemistry. A detailed post-mortem and histopathology was carried out on all animals following death or euthanasia at the end of the 24-h monitoring period. Control animals (Group 2) all survived until the end of the 24-h monitoring period with normal pathophysiological parameters. Histopathology showed only minimal passive congestion of the lung. Following exposure to phosgene (Group 1) there was one survivor to 24 h, with the remainder dying between 16.5 and 23 h (mean = 20 h). Histopathology from these animals showed areas of widespread pulmonary oedema, petechial haemorrhage and bronchial epithelial necrosis. There was also a significant increase in lung wet weight/body weight ratio (P < 0.001). During and immediately following exposure, a transient decrease in oxygen saturation and stroke volume index was observed. From 6 h there were significant decreases in arterial pH (P < 0.01), P(a)O(2) (P < 0.01) and lung compliance (P < 0.01), whereas oxygen delivery and consumption was reduced from 15 h onwards in phosgene-exposed animals. Mean pulmonary artery pressure of phosgene-exposed animals was increased from 15 h post-exposure, with periods of increased pulmonary vascular resistance index being recorded from 9 h onwards. We have developed a reproducible model of phosgene-induced lung injury in the anaesthetized pig. We have followed changes in cardiovascular and pulmonary dynamics for up to 24 h after exposure in order to demonstrate evidence of primary acute lung injury from 16 h post-exposure. Histopathology showed evidence of widespread damage to the lung and there was also a significant increase in lung wet weight/body weight ratio (P < 0.001).

The treatment of Lewisite burns with laser debridement---'lasablation'

Lewisite (dichloro (2-chlorovinyl) arsine) was first synthesised in 1918 and its potential for use in military confrontations as a vesicant agent has been widely recognised. These agents cause blistering skin reactions with resultant full thickness burns. Effective treatments to date have been delayed by the lack of suitable animal models. Porcine skin has recently been used successfully to model the development and natural history of these burn injuries. A large white pig model (n=6) was employed to investigate the effectiveness of CO(2) and Erbium-YAG lasers (EYL) in laser dermabrasion of established Lewisite burns. Burns underwent treatment at 4 days post-exposure and were assessed at 1, 2 and 3 weeks, thereafter, for the rate of epithelial healing. The re-epithelialisation rates in the laser dermabraded groups were accelerated by a factor of four compared to untreated controls by the first week (analysis of vartiance, ANOVA, P=0.006 for pulsed CO(2) and P=0.011 for Erbium-YAG). Ablation of the burn eschar was thought to accelerate the rate of healing by causing partial debridement. This method has been termed 'lasablation' and represents a significant advance in the clinical management of this type of injury.