J Trauma
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Closed-loop algorithms and resuscitation systems are being developed to control IV infusion rate during early resuscitation of hypovolemia. Although several different physiologic variables have been suggested as an endpoint to guide fluid therapy, blood pressure remains the most used variable for the initial assessment of hemorrhagic shock and the treatment response to volume loading. Closed-loop algorithms use a controller function to alter infusion rate inversely to blood pressure. ⋯ Proportional-integral and fuzzy logic algorithms reduced mean fluid volume requirements compared with the nonlinear decision table; and (4) several algorithms have been constructed to the specific mechanism of injury and the volume expansion properties of different fluids. Closed-loop systems are undergoing translation from animal to patient studies. Future smart resuscitation systems will benefit from new noninvasive technologies for monitoring blood pressure and the development of computer controlled high flow intravenous pumps.
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Most prehospital medical interventions during civilian and military trauma casualty transport fail to utilize advanced decision-support systems for treatment and delivery of medical interventions, particularly intravenous fluids and oxygen. Current treatment protocols are usually based on standard vital signs (eg, blood pressure, arterial oxygen saturation) which have proven to be of limited value in detecting the need to implement an intervention before cardiovascular collapse. A primary objective of the US Army combat casualty care research program is to reduce mortality and morbidity during casualty transport from the battlefield through advanced development of a semiautomated decision-support capability for closed-loop resuscitation and oxygen delivery. ⋯ We propose that derived indices based on currently available technology for continuous monitoring of specific hemodynamic, autonomic, and/or metabolic responses could provide earlier recognition of hemorrhage than current standard vital signs and allow intervention before the onset of circulatory shock. Because of this, such indices could provide improved feedback for closed-loop control of patient resuscitation and oxygen delivery. These technological advances could prove instrumental in advancing decision-support capabilities for prehospital trauma care during transport to higher levels of care in both the military and civilian environments.
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Military operations, mass casualty events, and remote work sites present unique challenges to providers of immediate medical care, who may lack the necessary skills for optimal clinical management. Moreover, the number of patients in these scenarios may overwhelm available health care resources. Recent applications of closed-loop control (CLC) techniques to critical care medicine may offer possible solutions for such environments. ⋯ Some potential advantages of CLC in patient management include limiting task saturation when there is simultaneous demand for cognitive and active clinical intervention, improving quality of care through optimization of the titration of medications, conserving limited consumable supplies, preventing secondary insults in traumatic brain injury, shortening the duration of mechanical ventilation, and achieving appropriate goal-directed resuscitation. The uses of CLC systems in critical care medicine have been increasingly explored across a wide range of therapeutic modalities. This review will provide an overview of control system theory as applied to critical care medicine that must be considered in the design of autonomous CLC systems, and introduce a number of clinical applications under development in the context of deployment of such applications to austere environments.
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Outcome in patients with traumatic brain injury (TBI) is often affected by secondary insults including posttraumatic cerebral infarction (PTCI). The incidence of PTCI after TBI was previously reported to be 2% with no mortality impact. We suspected that recent advances in imaging modalities and treatment might affect incidence and outcome. We sought to define the incidence and mortality impact of PTCI. We also identified risk factors associated with PTCI. ⋯ The incidence of PTCI in patients with severe TBI is higher after severe brain injury than previously thought. PTCI has a significant impact on mortality and LOS. The presence of a blunt cerebral vascular injury, the need for craniotomy, or treatment with factor VIIa are risk factors for PTCI. Recognition of this secondary brain insult and the associated risk factors may help identify the group at risk and tailor management of patients with severe TBI.
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Comparative Study
Femoral shortening after surgical treatment of trochanteric fractures in nongeriatric patients.
Femoral shortening is a well-known clinical finding after surgical treatment of per- and intertrochanteric fractures. Particularly, in geriatric patients with poor bone quality and unstable fracture types, secondary compression of these fractures often leads to length inequality of the lower limbs. In younger patients with good bone quality and mobilization with delayed weight bearing, limb length shortening is expected to be a rare complication. The purpose of this study was to analyze incidence and degree of femoral shortening in patients younger than 60 years of age after fixation of different types of per- and intertrochanteric fractures. In addition, we compared the results of two different implants, which were used for operative treatment. ⋯ Femoral shortening after operative treatment of per- and intertrochanteric fractures was found to be a common clinical finding in nongeriatric patients. Nearly half of them showed a lower limb length inequality after fracture fixation. The degree of the shortening was rather low and depended mainly on the fracture type. Comparing the two different implants used for operative treatment, a cephalomedullary nail was more successful in preventing limb length discrepancy in unstable fracture types than dynamic hip screw.