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 environmental and logistical constraints of the prehospital setting make it a challenging place for the treatment of trauma patients. This is perhaps more pronounced in the management of battlefield casualties before extraction to definitive care. In seeking solutions, interest has been renewed in implementing damage control resuscitation principles in the prehospital setting, a concept termed remote damage control resuscitation. ⋯ Management of trauma-related airway and respiratory compromise is evolving, with scope to improve on currently accepted practices. The purpose of this review is to highlight the challenges of treating patients in the prehospital setting and suggest potential solutions. In doing so, we hope to maintain the enthusiasm from people in the field and highlight areas for prehospital specific research and development, so that improved rates of casualty survival will continue.
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In past and ongoing military conflicts, the use of whole blood (WB) as a resuscitative product to treat trauma-induced shock and coagulopathy has been widely accepted as an alternative when availability of a balanced component-based transfusion strategy is restricted or lacking. In previous military conflicts, ABO group O blood from donors with low titers of anti-A/B blood group antibodies was favored. Now, several policies demand the exclusive use of ABO group-specific WB. ⋯ Emergency settings are often chaotic and resource limited, factors well known to increase the potential for human errors. Using ABO group-specific WB in emergencies may delay treatment because of needed ABO typing, increase the risk of clinical HTRs, and increase the severity of these reactions as well as increase the danger of underresuscitation due to lack of some ABO groups. When the clinical decision has been made to transfuse WB in patients with life-threatening hemorrhagic shock, we recommend the use of group O WB from donors with low anti-A/B titers when logistical constraints preclude the rapid availability of ABO group-specific WB and reliable group matching between donor and recipient is not feasible.
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Through necessity, military medicine has been the driver of medical innovation throughout history. The battlefield presents challenges, such as the requirement to provide care while under threat, resource limitation, and prolonged evacuation times, which must be overcome to improve casualty survival. Focus must also be placed on identifying the causes, and timing, of death within the battlefield. ⋯ We must also carry on working alongside our civilian colleagues so that the benefits of translational experience are not lost. This review describes several countries current military approaches to prehospital trauma care. These approaches, refined through a decade of experience, merit consideration for integration into civilian prehospital care practice.
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Trauma remains the leading cause of death with bleeding as the primary cause of preventable mortality during the first 24 h following trauma. When death occurs, it happens quickly, typically within the first 6 h after injury. One of four patients to arrive in the emergency department after trauma is already in the state of acute traumatic coagulopathy and shock. ⋯ In contrast, there is an iatrogenic coagulopathy that occurs secondary to uncritical volume therapy leading to acidosis, hypothermia, and hemodilution. This coagulopathy then may be an integral part of the "vicious cycle" when combined with acidosis and hypothermia. The present article summarizes an update on the principal mechanisms and triggers of the coagulopathy of trauma including traumatic brain injury.
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Comparative Study
Hemostatic function of apheresis platelets stored at 4 °C and 22 °C.
Platelet refrigeration decreases the risk of bacterial contamination and may preserve function better than standard-of-care room temperature (RT) storage. Benefits could include lower transfusion-related complications, decreased costs, improved hemostasis in acutely bleeding patients, and extended shelf life. In this study, we compared the effects of 22°C and 4°C storage on the functional and activation status of apheresis platelets. ⋯ Apheresis platelets stored at 4°C maintain more viable metabolic characteristics, are hemostatically more effective, and release fewer proinflammatory mediators than apheresis platelets stored at RT over 5 days. Given the superior bacteriologic safety of refrigerated products, these data suggest that cold-stored platelets may improve outcomes for acutely bleeding patients.