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Available from: Bryan A Cotton, Aug 23, 2015
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    ABSTRACT: Trauma is the leading cause of death in young adults and acute blood loss contributes to a large portion of mortality in the early post-trauma period. The recognition of lethal triad of coagulopathy, hypothermia and acidosis has led to the concepts of damage control surgery and resuscitation. Recent experience with managing polytrauma victims from the Iraq and Afghanistan wars has led to a few significant changes in clinical practice. Simultaneously, transfusion practices in the civilian settings have also been extensively studied retrospectively and prospectively in the last decade. Early treatment of coagulopathy with a high ratio of fresh frozen plasma and platelets to packed red blood cells (FFP:platelet:RBC), prevention and early correction of hypothermia and acidosis, monitoring of hemostasis using point of care tests like thromoboelastometry, use of recombinant activated factor VII, antifibrinolytic drugs like tranexamic acid are just some of the emerging trends. Further studies, especially in the civilian trauma centers, are needed to confirm the lessons learned in the military environment. Identification of patients likely to need massive transfusion followed by immediate preventive and therapeutic interventions to prevent the development of coagulopathy could help in reducing the morbidity and mortality associated with uncontrolled hemorrhage in trauma patients.
    01/2011; 1(1):51-6. DOI:10.4103/2229-5151.79282
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    ABSTRACT: Fluid resuscitation in trauma patients with hemorrhagic shock is controversially discussed in the literature. The coincidence of brain injury complicates management of these patients. This article summarizes the current knowledge on nonblood component fluid resuscitation and choice of fluids in patients with multiple trauma. Whereas current evidence suggests the efficacy of fluid therapy in hemorrhagic shock without active bleeding, experimental and clinical data demonstrate that aggressive volume challenge may be futile or even deleterious in the setting of uncontrolled hemorrhage. Large amounts of isotonic crystalloids may be associated with hypothermia, acidosis and inflammation. In patients with traumatic brain injury hypertonic solutions may positively influence inflammation and intracranial pressure without affecting neurologic outcome or mortality. To date no large-scale clinical studies exist to either support or refute the use of nonblood component fluid resuscitation of hemorrhagic shock in trauma patients. The optimal choice of fluid remains to be determined, but existing evidence suggests avoiding crystalloids in favor of hypertonic solutions. The role of modern, iso-oncotic colloids in the treatment of hemorrhagic shock has not yet been sufficiently defined. In patients with concomitant brain injury, arterial hypotension must be avoided and infusion of hypotonic solutions is obsolete, whereas administration of hypertonic solutions may exert beneficial effects beyond hemodynamic stabilization.
    Current opinion in anaesthesiology 02/2011; 24(2):202-8. DOI:10.1097/ACO.0b013e3283445326 · 2.53 Impact Factor
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    ABSTRACT: The indications of renal angioembolization for patients with high-grade renal trauma (HGRT) are based on angiographic criteria to reduce the failure rate of conservative management (CM). There is no consensus to predict or exclude an indication of renal angioembolization with a computed tomography (CT) scan. The aim of this study was to evaluate CT-specific criteria to predict or exclude the need for renal embolization. All traumatized patients admitted with renal injury were considered between 2005 and 2009. We included all patients who had an HGRT (classified by American Association for the Surgery of Trauma Organ Injury Scale grade≥3) treated by CM. We collected the demographic, CT, angiographic, management, and outcome data for these patients. CT criteria were retrospectively studied to define their predictive values for renal embolization. Among 101 patients with renal injury, 58 were HGRT, and 53 of them were treated by CM. Ten patients (19%) received renal embolization because of an ongoing renal hemorrhage. There was no significant difference for urologic interventions (2 [20%] vs. 7 [16%]), CM failure rate (1 [10%] vs. 2 [5%]), and during hospital stay between these patients and those who did not received embolization. None of the CT criteria had a negative predictive value for renal embolization to 100%, only the absence of intravascular contrast extravasation associated with a perirenal hematoma rim distance<25 mm excludes an indication for embolization. In patients with HGRT who had bleeding, a strategy of targeted angiography can be realized safely in using specific CT scan criteria that can predict with high accuracy and exclude the need for embolization, without reducing the success rate of CM.
    The Journal of trauma 05/2011; 70(5):1219-27; discussion 1227-8. DOI:10.1097/TA.0b013e31821180b1 · 2.96 Impact Factor
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