Shock : molecular, cellular, and systemic pathobiological aspects and therapeutic approaches : the official journal the Shock Society, the European Shock Society, the Brazilian Shock Society, the International Federation of Shock Societies
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The Trauma Hemostasis and Oxygenation Research Network held its third annual Remote Damage Control Resuscitation Symposium in June 2013 in Bergen, Norway. The Trauma Hemostasis and Oxygenation Research Network is a multidisciplinary group of investigators with a common interest in improving outcomes and safety in patients with severe traumatic injury. The network's mission is to reduce the risk of morbidity and mortality from traumatic hemorrhagic shock, in the prehospital phase of resuscitation through research, education, and training. ⋯ The prehospital phase of resuscitation is critical in these patients. If shock and coagulopathy can be rapidly identified and minimized before hospital admission, this will very likely reduce morbidity and mortality. This position statement begins to standardize the terms used, provides an acceptable range of therapeutic options, and identifies the major knowledge gaps in the field.
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Remote damage control resuscitation is a recently defined term used to describe techniques and strategies to provide hemostatic resuscitation to injured patients in the prehospital setting. In the civilian setting, unlike the typical military setting, patients who require treatment for hemorrhage come in all ages with all types of comorbidities and have bleeding that may be non-trauma related. Thus, in the austere setting, addressing the needs of the patient is no less challenging than in the military environment, albeit the caregivers are typically not putting their lives at risk to provide such care. ⋯ The Mayo Clinic program essentially takes a standard-of-care treatment algorithm, by which the patient would be treated in the emergency department or trauma bay, and projects that forward into the rural environment with specially trained prehospital personnel and special resources. Royal Caribbean Cruises Ltd has adapted a traditional military field practice of transfusing warm fresh whole blood, adding significant safety measures not yet reported on the battlefield (see within this Supplement the article entitled "Emergency Whole Blood Use in the Field: A Simplified Protocol for Collection and Transfusion"). The details of development, implementation, and preliminary results of these two civilian programs are described herein.
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Recent studies have demonstrated that intralipid (ILP) conferred myocardial protection against ischemia-reperfusion (IR) injury through activation of reperfusion injury salvage kinase (RISK) pathway. As RISK signal has been shown to be impaired in hypertrophied myocardium, we investigated whether ILP-induced cardiac protection was maintained in hypertrophied rat hearts. Transverse aortic constriction was performed on male Sprague-Dawley rats to induce left ventricular hypertrophy, then sham-operated or hypertrophied rat hearts were isolated and perfused retrogradely by the Langendorff for 30 min (equilibration) followed by 40 min of ischemia and then 120 min of reperfusion. ⋯ In contrast, ischemic preconditioning increased the phosphorylation of Akt, ERK1/2 and GSK3β, improved heart pump function, and reduced myocardial necrosis in sham-operated hearts, a phenomenon partially attenuated by ventricular hypertrophy. Interestingly, GSK inhibitor SB216763 conferred cardioprotection against IR injury in sham-operated hearts, but failed to exert cardioprotection in hypertrophied myocardium. Our results indicated that ventricular hypertrophy abrogated ILP-induced cardioprotection against IR injury by alteration of RISK/GSK3β signal.
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At the 2013 Traumatic Hemostasis and Oxygenation Research Network's Remote Damage Control Resuscitation symposium, a panel of senior blood bankers with both civilian and military background was invited to discuss their willingness and ability to supply prehospital plasma for resuscitation of massively bleeding casualties and to comment on the optimal preparations for such situations. Available evidence indicates that prehospital use of plasma may improve remote damage control resuscitation, although level I evidence is lacking. This practice is well established in several military services and is also being introduced in civilian settings. ⋯ Prehospital use of plasma should occur within the framework of clinical algorithms and prospective clinical studies. Clinicians have an ethical responsibility to both patients and donors; therefore, the introduction of new clinical capabilities of transfusion must be safe, efficacious, and sustainable. The panel agreed that although these problems need further attention and scientific studies, now is the time for both military and civilian transfusion systems to prepare for prehospital use of plasma in massively bleeding casualties.
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The control of torso and junctional zone bleeding in combat casualties is particularly challenging because of its noncompressible nature. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has demonstrated promise in translational large animal and early clinical series as an effective resuscitation and hemorrhage control adjunct. However, it is unknown what proportion of combat casualties has an injury pattern and clinical course that is amenable to REBOA deployment. ⋯ The median (interquartile range) time to death in patients dying en route was 75 (42-109) min, and the median prehospital time for casualties admitted to hospital was 61 (34-89) min. One-in-five severely injured UK combat casualties have a focus of hemorrhage in the abdomen or pelvic junctional region potentially amenable to REBOA deployment. The UK military should explore REBOA as a potential en route hemorrhage control and resuscitation adjunct.