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.

Blunt abdominal trauma: initial resuscitation followed by clinical and focused abdominal sonography assessment important diagnostic tools of organ injury due to restricted use of CT-scan in a tertiary care in India

Background: Blunt abdominal trauma (BAT) is one of the common causes of admission in surgical ward in any hospital. It requires high level of suspicion, urgent evaluation and timely management to decrease morbidity and mortality. Objective was to evaluate the role of clinical and ultrasound assessment in early diagnosis of intra-abdominal injury following blunt abdominal trauma and follow up in patients with intraabdominal injury for detecting complications.Methods: 130 patients who presented to the emergency room were evaluated by clinical and focused abdominal sonography for trauma (FAST) and follow-up sonography was done after 6-12 hours upto 72 hours.Results: In our study, road traffic accidents (RTA) were the most common cause of blunt abdominal trauma (70.76%) with 75% patients being were males. X-ray erect abdomen and ultrasound of the abdomen were the most sensitive investigation for hollow viscous injury and solid organ injuries, respectively, with bowel (38.33%) and liver injury (26.67%) being the most common organ involved in this study. This study found sensitivity (93.7%) and specificity (98.5%) of focused abdominal ultrasonography (FAST).Conclusions: Initial resuscitation followed by clinical and ultrasonography assessment is considered the best modality in initial evaluation of blunt abdominal trauma patients as it is noninvasive, readily available, and requires minimal preparation time and also due to restricted use of modern amenities such as CT-scan in tertiary care in India.

The differential for chest pain: when the most common cause is not the answer-a case of de novo esophageal bezoar

Background Having a broad differential and knowing how to manage the different possibilities in a patient with chest pain is important. Esophageal bezoars are rare entities and are even less common in patients without any recent hospitalizations, known achalasia, or nasogastric tubes. Despite their rarity, having it in one’s differential, and knowing how to manage it is important. Case presentation This case presents a patient with mega-esophagus secondary to an esophageal bezoar; and runs through the gamut of morbid chest pathophysiology, its differential, work-up, and management. The case is interesting in that the patient’s initial presentation brings to mind a bevy of feared chest issues to include myocardial infarction, dissection, pulmonary embolus, achalasia, and perforation. Conclusion This clinical case highlights more than just the rare diagnosis of esophageal bezoar. It also goes through initial resuscitation, key concerns, “can’t miss diagnoses”, and finally discusses the feared end state of an esophageal perforation.

Timing Assessment of Response to Fluid Challenge in Patients with Septic Shock

Objectives: Fluid challenge (FC) is most commonly used for fluid responsiveness (FR) evaluation, with a wide divergence in assessment time choices. Therefore, we aimed to explore the optimal assessment time for FC in patients with septic shock. Methods: A prospective cohort study was conducted. Septic shock patients who had experienced initial resuscitation and required an FC with 500 mL 4% gelatin or normal saline (NS) over 5-10 min were included. FR was defined by an increase in cardiac index (CI) >10%. FR and other predefined variables were recorded at baseline (Tb), immediately (T0), and at 10 (T1), 30 (T2), 45 (T3), 60 (T4), 90 (T5), and 120 (T6) min after FC. The incidence of FR and hemodynamic variables at predefined time points were recorded. Data were analyzed by repeated measures of analysis of variance. Results: 63 patients were enrolled, with 43 in the gelatin group and 20 in the NS group. Among the 45/63 (71%) responders, 31 were responded at T0 (ER), while 14 responded at T1 or later (LR). The proportion of NR, ER and LR was comparable between gelatin and NS groups. After FC, the time course of FR status was slightly different between gelatin and NS groups. In the gelatin group, FC induced most responders (69%, 31/45) and frequency of CI maximum (35%, 11/31) at T2 and sustained a positive FR status until T4; while in the NS group, FC induced most responders (55%, 11/20) and frequency of CI maximum (64%, 9/14) at T1, and sustained FR status until T1. Conclusions: Different time courses of FR were found between gelatin and NS group patients undergoing FC. Thus, when NS is used, FR should be performed within 10 min, while it is better to extend the assessment time to 30 min after FC when gelatin is used.

Management of solid organ injury in patient of blunt abdominal trauma

Background: In this ongoing era of 21st century, trauma is the leading cause of death in individuals between age 1 and 44. In trauma, also road traffic accidents (RTAs) are the major cause of death. Blunt abdominal trauma is a frequent emergency and is associated with significant morbidity and mortality.Methods: A prospective analysis of 50 patients of blunt abdominal trauma admitted in SMIMER hospital Surat within a span of 12 months was done. Unstable patients with initial resuscitation underwent focused assessment sonography for trauma (FAST). Failed resuscitation with free fluid in abdomen confirmed by FAST immediately shifted to operation theatre for laparotomy and proceed. Hemodynamically stable patients underwent computerized tomography of abdomen.Results: Most of the patients in our study were in the age group of 21-45 years with M:F ratio of 4:1. RTAs (62%) was the most common mechanism of injury. Spleen (38%) was the commonest organ injured and the most common surgery performed was splenectomy. In total non-operative management (NOM) was done in 58% of cases and surgical management was done in 42% of cases.Conclusions: Appropriate patient selection, early diagnosis and repeated clinical examination and use of appropriate investigations forms the key in management of blunt abdominal trauma. To conclude, initial resuscitation measures and correct diagnosis forms the most vital part of blunt abdominal trauma management.