Hemorrhagic Resuscitation Guided by Viscoelastography in Far-Forward Combat and Austere Civilian Environments: Goal-Directed Whole-Blood and Blood-Component Therapy Far from the Trauma Center

Modern approaches to resuscitation seek to bring patient interventions as close as possible to the initial trauma. In recent decades, fresh or cold-stored whole blood has gained widespread support in multiple settings as the best first agent in resuscitation after massive blood loss. However, whole blood is not a panacea, and while current guidelines promote continued resuscitation with fixed ratios of blood products, the debate about the optimal resuscitation strategy—especially in austere or challenging environments—is by no means settled. In this narrative review, we give a brief history of military resuscitation and how whole blood became the mainstay of initial resuscitation. We then outline the principles of viscoelastic hemostatic assays as well as their adoption for providing goal-directed blood-component therapy in trauma centers. After summarizing the nascent research on the strengths and limitations of viscoelastic platforms in challenging environmental conditions, we conclude with our vision of how these platforms can be deployed in far-forward combat and austere civilian environments to maximize survival.

Serum Hs-CRP level and clinical significance of patients with stress ulcer caused by massive blood loss after trauma

Stress ulcer refers to a specific type of irritation of the inner wall of the gastrointestinal tract that occurs rapidly due to acute physiological stress such as severe disease, infection, or trauma. This study investigated the serum Hs-CRP level and clinical significance of patients with stress ulcers caused by massive blood loss after trauma. For this purpose, we studied 113 patients with enormous blood loss after trauma. During the study, 26 patients developed stress ulcers. Therefore, patients with massive blood loss after trauma were divided into two groups with and without stress ulcers. In addition to clinical and demographical evaluations, serum Hs-CRP levels were measured by ELISA test method in all patients at baseline, 6, and 12 days after starting the study. Results showed that 24 patients were excluded from the study due to termination of cooperation or death. Finally, 89 patients participated in the final analysis. Of these 89 patients, 26 developed stress ulcers. There was a significant difference between the two groups with stress and non-stress ulcers in terms of mean age (P=0.001) and gender (P=0.041). Also, there was a significant difference between the two groups regarding re-bleeding (P=0.012), the number of hospitalization days (P=0.001), and a decrease in hemoglobin (P=0.035). But there was no difference between the two groups regarding the need for re-surgery (P=0.276). The results of this study showed that increased serum hs-CRP levels are directly related to stress ulcers. Patients with higher serum Hs-CRP levels were more likely to develop stress ulcers than patients without stress ulcers during six days (P=0.04) and twelve days after starting the study (P=0.001). Current research results also show that the prevalence of stress ulcers occurs in men more than women. The risk of stress ulcers increases among older patients. People with stress ulcers also lose more hemoglobin, and finally, patients with more trauma and more extended hospital stays have a higher chance of developing stress ulcers.

Comparison of the effectiveness of blood transfusion and reinfusion

Studies by atomic force and scanning electron microscopy have shown that erythrocytes of foreign blood have morphological defects. The sequestration of foreign erythrocytes makes it difficult for the erythron to selfrepair. The actual solution to this problem is the application of the blood reinfusion technique using the Cell Saver apparatus. Transfusion of autoerythra suspension, harvested using the Cell Saver apparatus during the operation, stabilizes red blood counts in the early post-transfusion period in patients and reduces the manifestation of massive hemotransfusion syndrome. Hardware reinfusion of erythrocytes is effective and safe for massive blood loss in obstetrics. Reinfusion dictates the need for parallel correction of all blood parameters. Application of the principles of patient blood management can reduce the transfusion load, improve the quality of medical care.

Possibilities of non-operative and minimally invasive organ-preserving spleen injuries management in blunt abdominal injuries in adults

The Objective was to assess and improve the treatment results of victims with spleen injury in blunt abdominal trauma by using high-tech minimally invasive methods of diagnosis and treatment.Methods and materials. The article analyzed the results of treatment of 86 patients with isolated and combined blunt spleen injuries who received conventional surgery, and 52 similar patients who were treated in accordance with the new algorithm. This algorithm included conventional splenectomy for unstable hemodynamics and non-operative and minimally invasive management for stable hemodynamics after MSCT. In the absence of CT signs of ongoing bleeding, non-operative management was performed, if ongoing bleeding signs were detected, angiography with selective angioembolization was performed.Results. In both groups, most of the victims with blunt spleen injury were admitted to the trauma center after traffic accidents and catatraumas. There were no statistically significant differences in the injury severity (ISS, Tsibin scales), and the condition severity (VPH-SP). The tactics of non-operative and minimally invasive management was applied in 31 patients of the prospective group with stable hemodynamics. Non-operative management was performed on 16 patients of the prospective group. Four patients of this group underwent angiography and selective embolization of the branches of the splenic artery. In the retrospective group, there was a greater number of local complications compared to the prospective group (p=0.006). The decrease in the number of visceral and generalized complications was statistically insignificant (p>0.05). In the retrospective group, 21 victims died. Of these, 12 patients died from severe combined trauma and massive blood loss during the first 24 hours. In the prospective group, the total number of deaths was 10 patients. Of these, 6 died from polytrauma with acute massive blood loss, 1 – from severe traumatic brain injury, 1 – from PE, 2 – from sepsis. In the prospective group, among the patients with stable hemodynamics who had conservative treatment of abdominal trauma, 2 deaths were observed in the long-term period due to severe traumatic brain injury and PE.Conclusion. Organ-preserving management was carried out in 26 of 52 (50 %) patients, the number of performed diagnostic laparocenteses was reduced by 50.6 %, laparoscopies – by 16.5 %, laparotomies – by 60.7 %, the duration of inpatient treatment of surviving patients was more than for 7 days, mortality – by 5.2 %.

Stopping life-threatening bleeding is one of the essential skills of simulation training in emergency medical care

More than 5 million people around the world die every year from severe injuries and their complications, among which massive blood loss is in the first place. The introduction of practical exercises for training in stopping massive bleeding using simulators and modern means will not only improve the quality of care at the prehospital and early hospital stages, but also significantly improve the process of all simulation training.

Carbetocin versus Oxytocin in Active Management of 3rd stage of Labour following Vaginal Delivery

Background: Every day more than 220 women around the world die from severe bleeding after childbirth. Globally post-partum hemorrhage is the number one direct cause of maternal mortality. Most postpartum hemorrhages are caused by uterine atony and occur in the immediate postpartum period. Most of these tragic deaths can be prevented by active management of third stage of labour. Active management of the third stage of labor should be practiced routinely to decrease the risk of postpartum hemorrhage. Oxytocin is used for enhancing uterine contraction after delivery. But oxytocin has some limitations like shorter half- life, less contraction time and more side effects, whereas carbetocin has prolonged duration of action which ensures more contraction time and less adverse effects. This study was done to see the efficacy and safety of carbetocin over oxytocin for prevention of PPH after vaginal delivery. Methodology: A randomized controlled clinical trial was conducted in the Department of Obstetrics and Gynecology, Shaheed Suhrawardy Medical College and Hospital, Dhaka, Bangladesh over a period of 9 months from January 2015 to September 2015. Ninety four patients undergoing vaginal delivery at term were randomized into two groups receiving either 10IU oxytocin or 100 μg carbetocin. Outcome measures such as primary PPH, massive blood loss, need for additional uterotonic drug, additional blood transfusion as well as adverse effects were documented. Results: In this study, massive blood loss did not occur none of patients in carbetocin group. But massive blood loss occured 6.4% women of oxytocin group. Further fundal massage , immediate blood transfusion and additional uterotonics didn’t need any patient in carbetocin group. In oxytocin group, fundal massage required in 8.5% of women, blood transfusion needed in 10.6% patients and additional uterotonics needed in 10.6% women. Average amount of blood loss was 88 ml less in carbetocin group and adverse effects of drugs were almost similar in both group. Primary PPH developed in oxytocin group 8.5% but none of patients had developed PPH in carbetocin group. Conclusion: Carbetocin is an effective new drug than oxytocin for prevention of postpartum hemorrhage in vaginal delivery. Bioresearch Commu. 7(1): 927-931, 2021 (January)

Peculiarities of cytolytic syndrome development with associated injury of the abdominal organs and massive blood loss in the experiment

The function of the organs responsible for detoxification processes, in particular the liver, deserves a special role in the conditions of combined trauma. It is proved that ischemia-reperfusion of the limb caused by the imposition of a tourniquet, is the cause of significant toxemia. Under such conditions, it becomes clear that the detoxification function may be impaired, especially against the background of blunt combined trauma to the abdominal organs complicated by massive bleeding. Changes in the detoxification function of the liver are indicated by markers of the cytolytic syndrome. However, there is no clear understanding of how ischemia - limb reperfusion affects the development of cytolytic syndrome.Objective of research: to study the effect of massive blood loss associated with ischemia-reperfusion of the limb on the cytolytic syndrome indicators in case of injury of the abdominal organs. Materials and methods. 100 mature albino male Wistar rats with the body weight of 190-220 grams kept on standard vivarium forage were used in the experiment. The animals were divided into the control and 3 research groups (containing 10 animals each). Arresting bleeding tourniquet was applied proximally on the lower limbs of rats from the first research group for 120 minutes under thiopental-sodium anesthesia (40 mg/kg-1), which caused development of ischemic-reperfusion. Closed abdominal injury was simulated by means of delivering two dosed blows in the region of the abdominal cavity in the second research group; massive blood loss was simulated by means of cutting the femoral vessels and bloodletting from 25 to 30 % of the circulating blood volume in the group. Injuries from the first two groups were combined in the third group. The control group of animals received anesthesia without formation of any injuries. With the aim to determine alterations of cytolytic syndrome the activity of enzymes – markers of cytolytic syndrome ALT and AST were determined by means of a unified method. The animals of the research groups were removed from the experiment under thiopental-sodium anesthesia by means of the total bloodletting from the heart.Results. Analysis of the results of the study found that cytolytic syndrome develops irrespective of the kind of injuries simulated. Thus, even during a day of post-traumatic period ALT and AST activity increases which is clearly registered in all the three research groups. Further destruction of cellular membranes increases till the 3rd day, which is manifested by a considerable increase of ALT and AST activity in the blood serum. This process continues till the 7th day. A tendency to ALT and AST decrease is observed only in the 1st group on the 7th day. Comparison of the 2nd and 3rd research groups within the time interval enables to understand that application of tourniquets on the limbs of animals with closed abdominal injury and massive bleeding deteriorates cytolytic processes.Conclusions: Simulated injuries in the research groups were associated with the occurrence of cytolytic processes possessing a tendency to develop in the period of early signs of traumatic disease. Ischemic-reperfusion syndrome of the limbs accelerates considerably the development of systemic changes with abdominal injuries and hypovolemic shock, which was manifested by a considerable increase of ALT and AST parameters in the group with abdominal trauma and massive blood loss and becoming higher than that of the control in end of the experiment.

The State of the Structure of the Brain Cortex at Different Times of the Postmortal Period after Massive Blood Loss and Blood Loss Complicated by Hemorrhagic Shock

Determine the time of death based on these characteristics. Aims: The aim of the study was to identify the features of changes in the structure of the cerebral cortex in different periods of the post - mortem period after massive blood loss and blood loss complicated by hemorrhagic shock, and to determine the age of death based on these data. Study Design: Cross-sectional study. Place and Duration of Study: Department of Medicine and Department of Forensic Medicine 2020 between. Methodology: The structures of the cortex from the Brodman sixth field of the large hemispheres of the brain were studied from 73 corpses of individuals who died from massive blood loss (MB) - 61 and blood loss complicated by hemorrhagic shock -12. The study of corpses with MB (group 1) was carried out in the period: 6-8 h (26), 8-10 h (6), 10-12 h (4), 12-14 h (6), 14-16 h ( 12), 16-24 h (5), 24-28 h (2) postmortem period. Research of corpses after hemorrhagic shock (group 2) were carried out after 6-8 hours (3), 12-14 (3), 18-20 (2), 24-28 (4). Histological preparations of the brain were first examined qualitatively, then quantitatively. Quantitative study of structures was carried out by the point method according To G. G. Avtandilov, the digital material was statistically processed by the Student – Fisher method. Results: Thus, at death from massive blood loss, as the post-mortem period increases, there is an increase in structural changes in cortical neurons,as well as an expansion of pericellular space. The vascular component of the cerebral cortex is also involved in destructive processes associated with an increase in the postmortem period, and an increase in perivascular spaces is observed. Conclusion: Comparative analysis of the data obtained showed that in the postmortem period after hemorrhagic shock (group 2), destructive changes in the cerebral cortex appear earlier and are more pronounced than in the case of death from massive blood loss (group 1). Similar expansion of perineuronal and perivascular spaces in the cerebral cortex reflects the persistence of thanatogenesis manifestations in different periods of the post-mortal period after death from massive blood loss and hemorrhagic shock.

Uterus Preservation Versus Caesarean Hysterectomy in Management of Placenta Accreta Spectrum: A Multicentre International Study

Objective: To compare peripartum outcomes of uterus preserving procedures to caesarean hysterectomy in women with placenta accreta spectrum (PAS), and to identify risk factors associated with adverse maternal outcomes. Design: Retrospective study (ClinicalTrials.gov identifier: NCT04384510) Setting:11 tertiary centres from 9 countries Population or Sample: women with of PAS who were managed in participating centres between January 1st, 2010 and December 31st, 2019. Women who had confirmed diagnosis with PAS with adequate documentation and follow-up, were considered eligible. Main Outcome Measures: Primary outcome was massive PAS-associated perioperative blood loss (intraoperative blood loss ≥ 2500 ml, bleeding associated massive transfusion protocol, or complicated by disseminated intravascular coagulopathy). Results: Out of 797 women, 727 were eligible for the study. Five hundred ninety-two (81.43%) women were managed by uterus preserving procedures versus 135 (18.56%) who underwent caesarean hysterectomy. After adjustment for significant or close-to-significance variables, type of management was not associated with higher risk of massive blood loss (aOR 1.71, 95% CI 0.78 - 3.81). Other factors that were significantly associated with higher risk of massive PAS-associated blood loss included body mass index, preoperative haemoglobin, centrally located placenta, diffuse placental invasion, parametrial invasion, and intrauterine foetal death. Conclusions: In the presence of sufficient experience, uterus preserving procedures may not be associated with higher risk of massive blood loss compared to caesarean hysterectomy. Funding: none

Congenital renal arteriovenous malformation: a rare cause of visible haematuria

We report a case of renal arteriovenous malformation (AVM) and describe its angioarchitecture and endovascular management. A 28-year-old male patient presented with visible painless haematuria. CT of the abdomen showed a right renal AVM. Digital subtraction angiography of the right renal vessels showed an AVM of middle and lower pole segmental arteries with communication to a large saccular aneurysm, which was arising from the right main renal vein. Complete occlusion of the AVM was done by using glue (a mixture of n-butyl-cyanoacrylate and lipiodol), resulting in nonvisualisation of the aneurysm on angiography. His vital signs were stable during the procedure. Follow-up CT after 12 months showed no residual flow in the aneurysm, normal upper pole renal parenchyma and nonvisualisation of AVM. Early diagnosis of this clinical entity is of paramount importance for proper management as it can cause massive blood loss and rapid clinical deterioration.