J Trauma
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Comparative Study
Effects of resuscitation from hemorrhagic shock on cerebral hemodynamics in the presence of an intracranial mass.
This study compares intracranial pressure, cerebral blood flow, and cerebral oxygen transport during hemorrhagic shock and following fluid resuscitation with crystalloid or colloid solution in a canine model with an epidural mass lesion. After placement of an epidural balloon, intracranial pressure was increased to 30 mm Hg for 5 minutes and then permitted to vary without further manipulation. Hemorrhagic shock was produced by the rapid removal of blood to achieve a mean arterial pressure of 55 mm Hg for 30 minutes. ⋯ Intracranial pressure was significantly lower immediately after resuscitation in the hetastarch group; it then gradually increased so that the difference was much less 1 hour later. Cerebral blood flow decreased during shock and was not restored by either fluid; cerebral oxygen transport fell further with resuscitation in both groups due to hemodilutional reductions in hemoglobin. Although colloid resuscitation improved systemic hemodynamics and maintained lower intracranial pressure, it failed, as did crystalloid resuscitation, to restore cerebral oxygen transport to prehemorrhagic shock levels.
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Exsanguination may be presumed in pale, mottled, unresponsive trauma victims with no palpable pulse nor spontaneous respirations with noncranial penetrating wounds. Under ideal circumstances, those victims initially witnessed to have some signs of life can be successfully revived in 5 to 25% of cases. ⋯ After confirming the witnessed cardiopulmonary arrest from presumed exsanguination, the four phases of resuscitation are restoring central oxygenation, controlling internal hemorrhage, re-establishing spontaneous cardiac function, and definitively repairing the injury. Regardless of the type or location of the noncranial penetrating injury, these phases must be accomplished sequentially to minimize the risks of cerebral and cardiac anoxia.
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The treatment of accidental hypothermia by extracorporeal circulation and internal rewarming can be life saving in patients unconscious from drug overdose or victims of accidental exposure to severe cold. Advantages are the rapidity of treatment, the provision of circulatory support, and a lessened chance of rewarming collapse, since peripheral vasodilation is paralleled by an increase in cardiac output. A premature diagnosis of clinical death was averted in two patients with rectal temperatures of 25 degrees C or below, and their lives were saved by the use of this technique.
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Hypertonic sodium chloride solutions: effect on hemodynamics and survival after hemorrhage in swine.
We evaluated the hemodynamic response of 12% shed blood replacement with 7.5% sodium chloride after a nonlethal hemorrhage in chronically instrumented swine. Compared to no treatment or Ringer's lactate infusion, the hypertonic salt solution was followed by increased cardiac output. ⋯ The mechanism appears to be by increased tissue perfusion as indicated by lower lactate values. Resuscitation with low-volume hypertonic sodium chloride may be life saving and life supporting during the initial treatment of trauma patients when conventional therapy is not available.
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Fifty-two tibial shaft fractures in 50 patients were treated with flexible medullary nails (Ender type). In 32 cases the fracture was closed and in the remaining 28 cases the fracture was open. Forty-eight of the 52 fractures united in an average time of 16.8 weeks and there were no cases of deep infection or osteomyelitis. ⋯ Dynamic controlled motion at the fracture site leads to early callus formation which is biomechanically and biologically favorable. The procedure is relatively easy to perform, short in duration, and requires little specialized equipment. Flexible medullary nailing is an alternative treatment modality for selected open and closed displaced tibial shaft fractures.