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Background: The aim of this study was to evaluate the application of pulse contour cardiac output (PiCCO) in patients with traumatic shock. Methods: Seventy-eight patients with traumatic shock were included and grouped. The control group (CG, n = 39) underwent fluid resuscitation through transthoracic echocardiography (TTE) monitoring, and the research group (RG, n = 39) received PiCCO-guided fluid resuscitation. Results: The mechanical ventilation time, duration of vasoactive drug use, and duration of stay in the intensive care unit were lower in the RG compared to the CG (P <.05). At 72 h after fluid resuscitation, the mean arterial pressure and central venous pressure in the RG were higher than those in the CG (P <.05). The stroke volume variation and distensibility index of the inferior vena cava were lower at 72 h after fluid resuscitation, but the levels of extravascular lung water, global end-diastolic volume index, and intrathoracic blood volume index were higher in the RG (P <.05). The levels of endothelial 1, nitrogen monoxide, tumor necrosis factor-α, procalcitonin, C-reactive protein, and partial pressure of carbon dioxide at 72 h after fluid resuscitation in the RG were lower than those in the CG (P <.05). Conclusion: PiCCO-guided liquid resuscitation may help to accurately evaluate the volumetric parameters, alleviate symptoms of ischemia and hypoxia, regulate hemodynamics and blood gas analysis, reduce inflammatory reactions, improve endothelial functions, and effectively guide the usage of vascular active drugs. [ABSTRACT FROM AUTHOR]

Introduction: Hydrogen ion concentration which is expressed as pH value is in human blood maintained in narrow physiological range (7.36-7.44 in arterial blood). This range is crucial for normal functioning of most biochemical reactions. Extreme acidosis with pH < 6.8 is incompatible with life, unless pathophysiologic process is rapidly reversed. Timely, standardized, and structured approach to assessment and management of extreme critical illness is essential to maximize the chances of patient's survival. Cases: We present a series of 3 critically ill patients admitted to Medical intensive care unit (MICU) diagnosed with extreme metabolic acidosis (pH ⩽ 6.8). Each patient was treated using C hecklist for E arly R ecognition and T reatment of A cute I llness and I N jury (CERTAIN) which is a standard decision support tool in our MICU. Causes of extreme metabolic acidosis included hemorrhagic shock, sepsis, and acute renal failure and diabetic ketoacidosis. Rapid assessment, prompt resuscitation (IV fluids, vasopressors, mechanical ventilation, and renal replacement), and application of specific causal treatment led to positive outcomes in all 3 patients. Discussion: Medical physiology textbooks set the lower limit of pH value at which life is possible to 6.8. However, examples from clinical practice show that if adequate resuscitation measures are taken early in the acute phase of the disease, the biochemical cascade of reactions that are considered irreversible (at pH ⩽ 6.8) may be reversed after all. Conclusion: Critical care approach to extreme metabolic acidosis is a prime example of applied clinical physiology where basic science and clinical practice connect. With these case series we show that timely and structured approach to critical illness shifts the boundaries of reversibility for some of the most severe physiologic derangements. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Hydrogen ion concentration which is expressed as pH value is in human blood maintained in narrow physiological range (7.36-7.44 in arterial blood). This range is crucial for normal functioning of most biochemical reactions. Extreme acidosis with pH < 6.8 is incompatible with life, unless pathophysiologic process is rapidly reversed. Timely, standardized, and structured approach to assessment and management of extreme critical illness is essential to maximize the chances of patient's survival. CASES: We present a series of 3 critically ill patients admitted to Medical intensive care unit (MICU) diagnosed with extreme metabolic acidosis (pH ≤ 6.8). Each patient was treated using Checklist for Early Recognition and Treatment of Acute Illness and INjury (CERTAIN) which is a standard decision support tool in our MICU. Causes of extreme metabolic acidosis included hemorrhagic shock, sepsis, and acute renal failure and diabetic ketoacidosis. Rapid assessment, prompt resuscitation (IV fluids, vasopressors, mechanical ventilation, and renal replacement), and application of specific causal treatment led to positive outcomes in all 3 patients. DISCUSSION: Medical physiology textbooks set the lower limit of pH value at which life is possible to 6.8. However, examples from clinical practice show that if adequate resuscitation measures are taken early in the acute phase of the disease, the biochemical cascade of reactions that are considered irreversible (at pH ≤ 6.8) may be reversed after all. CONCLUSION: Critical care approach to extreme metabolic acidosis is a prime example of applied clinical physiology where basic science and clinical practice connect. With these case series we show that timely and structured approach to critical illness shifts the boundaries of reversibility for some of the most severe physiologic derangements. [ABSTRACT FROM AUTHOR]

Hypotension, defined as systolic blood pressure less than 90 mm Hg, is recognized as a sign of hemorrhagic shock and is a validated prognostic indicator. The definition of hypotension, particularly in the elderly population, deserves attention. We hypothesized that the systolic blood pressure associated with increased mortality resulting from hemorrhagic shock increases with increasing age. The Los Angeles County Trauma Database was queried for all moderate to severely injured patients without major head injuries admitted between 1998 and 2005. Several fit statistic analyses were performed for each systolic blood pressure from 50 to 180 mm Hg to identify the model that most accurately defined hypotension for three age groups. The optimal definition of hypotension for each group was determined from the best fit model. A total of 24,438 patients were analyzed. The optimal definition of hypotension was systolic blood pressure of 100 mm Hg for patients 20 to 49 years, 120 mm Hg for patients 50 to 69 years, and 140 mm Hg for patients 70 years and older. The optimal systolic blood pressure for improved mortality in hemorrhagic shock increases significantly with increasing age. Elderly trauma patients without major head injuries should be considered hypotensive for systolic blood pressure less than 140 mm Hg. [ABSTRACT FROM AUTHOR]

Patients with hypertension have higher mortality rates from hemorrhagic shock (HS) than normotensive patients. Several inflammatory mediators such as tumor necrosis factor α (TNF-α) and interleukin 10 (IL-10) can be produced by HS and lead to multiple organ dysfunction and death. We investigated the effects of high dose (10 mg/kg/hr) and low dose (1 mg/kg/hr) propofol treatment after HS in conscious spontaneously hypertensive rats (SHRs). By withdrawing 40% of total blood volume from a femoral arterial catheter (6 ml/100 g body weight [BW]) formore than 30 min, HS was induced. The mean arterial pressure (MAP) and heart rate (HR) were monitored continuously for 24 hr after the start of blood withdrawal. Levels of biochemical parameters, including glutamic oxaloacetic transaminase (GOT), glutamic pyruvic transaminase (GPT), blood urea nitrogen (BUN), creatinine (Cre), creatine phosphokinase (CPK), and lactic dehydrogenase (LDH) were measured 30 min before and 0, 1, 3, 6, 9, 12, 18, and 24 hr after the 30-min blood withdrawal period. Cytokine levels, including TNF-α and IL-10 in the serum, were measured 1 hr after HS. The kidney, liver, and lung were removed for pathology assessment at 48 hr after HS. HS significantly increased blood GOT, GPT, BUN, LDH, CPK, TNF-α, and IL-10 levels in conscious SHRs. Posttreatment propofol decreased serum TNF-α level, increased serum IL-10 level, attenuated the severity of organ damage, and improved survival rate after HS. This treatment protected SHRs against HS-induced organ damage. Moreover, high-dose propofol had a more protective effect than low-dose propofol against HS in conscious SHRs. [ABSTRACT FROM AUTHOR]

Near-infrared spectroscopy (NIRS) has been used to measure regional tissue oxygen saturation (StO2) in skeletal muscle as an indicator of perfusion in trauma patients. In an effort to prospectively examine the usefulness of StO2 in identifying trauma patients in hemorrhagic shock, we evaluated the need for blood transfusion within 24 hours of injury as a marker of significant hemorrhage. A 6-month prospective, observational study was conducted at a university-affiliated, urban Level I trauma center using a convenience sample of 26 trauma patients thought to be at high risk for hemorrhagic shock. Baseline demographic data, vital signs, laboratory values, and amounts of fluid and blood products administered were collected. NIRS-derived StO2 values were measured for 1 hour after arrival to the trauma bay and the minimum value noted. A minimum StO2 less than 70 per cent correlated with the need for blood transfusion with a sensitivity of 88 per cent and a specificity of 78 per cent. The positive predictive value was 64 per cent and the negative predictive value was 93 per cent. The need for blood transfusion within 24 hours of arrival was not predicted by hypotension, tachycardia, arterial lactate, base deficit, or hemoglobin. StO2 may represent an important screening tool for identifying trauma patients who require blood transfusion or other limited medical resources. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 36-year-old male bicyclist who was diagnosed with hemorrhagic shock after struck by a high-speed motor vehicle. The patient had a computed tomography (CT) which shows hemoperitoneum with active extravasation from an injured recanalized umbilical vein. The patient had developed hypotension due to rib fractures. It notes that the hemorrhagic shock is the result of an injured recanalized umbilical vein.

Management of acute bleeding in patients who are Jehovah's Witnesses remains a challenge. Clearly, the most important concept is meticulous and early hemostasis to minimize ongoing blood loss. This is generally followed by supportive measures. Dilutional coagulopathy can present a real challenge, as therapeutic options are quite limited in this group of patients. We present a patient who arrived in hemorrhagic shock, and despite early surgical therapy, his significant blood loss caused dilutional coagulopathy that we treated with activated factor Vila. While use of factor Vila after injury is gaining popularity, data on its use in patients who are Jehovah's Witnesses is quite limited. In this case, we believe the product was life-saving. Most importantly, there were no religious objections to its use. In appropriate patients, when surgical bleeding is controlled and there is still evidence of dilutional coagulopathy, factor Vila may have a real role in patients, particularly those who are Jehovah's Witnesses. [ABSTRACT FROM AUTHOR]