Hemorrhagic shock and hemostatic resuscitation in canine trauma

Hemorrhage is a significant cause of death among military working dogs and in civilian canine trauma. While research specifically aimed at canine trauma is limited, many principles from human trauma resuscitation apply. Trauma with significant hemorrhage results in shock and inadequate oxygen delivery to tissues. This leads to aberrations in cellular metabolism, including anaerobic metabolism, decreased energy production, acidosis, cell swelling, and eventual cell death. Considering blood and endothelium as a single organ system, blood failure is a syndrome of endotheliopathy, coagulopathy, and platelet dysfunction. In severe cases following injury, blood failure develops and is induced by inadequate oxygen delivery in the presence of hemorrhage, tissue injury, and acute stress from trauma. Severe hemorrhagic shock is best treated with hemostatic resuscitation, wherein blood products are used to restore effective circulating volume and increase oxygen delivery to tissues without exacerbating blood failure. The principles of hemostatic resuscitation have been demonstrated in severely injured people and the authors propose an algorithm for applying this to canine patients. The use of plasma and whole blood to resuscitate severely injured canines while minimizing the use of crystalloids and colloids could prove instrumental in improving both mortality and morbidity. More work is needed to understand the canine patient that would benefit from hemostatic resuscitation, as well as to determine the optimal resuscitation strategy for these patients.     

Thoracic duct injury from blunt trauma

We have reported a case of traumatic chylothorax occurring as a rare complication of fracture dislocation of the dorsal spine. When conservative management by drainage, low-fat diet, and parenteral alimentation proved unsuccessful, thoracic duct ligation effected a cure.     

Hemorrhagic shock

The hemodynamic, metabolic, clotting, renal and pulmonary aspect of hemorrhagic shock are reviewed. Optimal management by transfusion, the use of anti-shock trousers and resuscitation are discussed.     

Hemorrhagic shock

Shock is a consequence of insufficient blood flow for adequate oxygenation at the cellular level. Early recognition of the signs permits prompt therapy to maintain the effective circulating volume before irreparable organ damage occurs. Classification of shock on the basis of percentage of blood loss is helpful in guiding initial management. Replacement of red blood cells may be required for acute blood loss of more than 25 percent of the patient's circulating volume. Adequate arterial PO2 is essential for maintaining cellular oxygenation.     

Injuries distracting from intraabdominal injuries after blunt trauma

While most conscious patients with severe intraabdominal injuries (IAI) will usually present with either abdominal pain or tenderness, there is a small group of awake and alert patients in whom the physical examination will be falsely negative because of the presence of associated extraabdominal (“distracting”) injuries. We sought to define the types of extraabdominal injuries that could lead to a false negative physical examination for potentially severe IAI in adult victims of blunt trauma. This study was prospectively performed on consecutive blunt trauma patients over a 14-month period in our level I trauma center. Inclusion criteria were as follows: (1) Glasgow Coma Scale score of 15; (2) age 18 years or older; and (3) computed tomography (CT) of the abdomen or diagnostic peritoneal lavage (DPL) performed regardless of initial physical examination findings. Patients were questioned specifically about the presence of abdominal pain and the initial abdominal examination was documented in addition to other extraabdominal injuries. Abdominal injuries were considered to be present based upon either abdominal CT findings or a positive DPL. Patients with and without abdominal pain or tenderness were compared for the presence of IAI. A total of 350 patients were enrolled. There were 142 patients with neither abdominal pain nor tenderness (group I) and 208 patients with either or both (group 2). Ten of the 142 patients (7.0%) in group I had IAI compared with 44 of the 208 patients (21.2%) in group 2 (P = .0003). Presence of pain and/or tenderness had a sensitivity of 82%, a specificity of 45%, a positive predictive value of 21%, and negative predictive value of 93%. All 10 patients in group 1, and 36 of the 44 group 2 patients, had associated extraabdominal injuries. Although the presence of abdominal pain or tenderness was associated with a significantly higher incidence of IAI, the lack of these findings did not preclude IAI.     

Rupture of the cervical esophagus from blunt trauma

A patient had a left anterolateral linear tear of the lower cervical esophagus with concomitant second rib fracture after a steering wheel injury. Diagnosis of the lesion was delayed because of initial absence of physical signs. Subsequent operative drainage and repair were unsuccessful.     

Proper management of renal artery injury from blunt trauma

Blunt trauma to renal arteries often receives suboptimal management because of delayed diagnosis, incomplete preoperative evaluation, associated injuries, or unknown functional capacity of the contralateral kidney. We propose a rational treatment plan from an analysis of our three cases and a review of 118 cases. Two thirds of the patients were male, and left-sided injuries predominated over right 42.9% to 30.6%. In 20 cases the insult was bilateral. Associated injuries occurred in 72%, averaging 1.6 injuries per case, of which one half were intra-abdominal. Flank and/or abdominal pain was present in 73% of cases, tenderness in 65%, and gross or microscopic hematuria in 74%. Repairs were attempted on 38 renal arteries. "Successful" repairs were accomplished in 16 arteries, while repairs failed in 22. Subsequent hypertension developed in 32% of successes. Repair should be attempted in stable patients with unilateral injury of less than four hours' duration, bilateral injuries of less than 20 hours' duration, or injuries with nonocclusion on arteriogram.     

Pseudoaneurysm of the breast after blunt trauma: successful treatment with ultrasound-guided compression

We present a case of breast pseudoaneurysm following a blunt trauma in a 58-year-old woman. Few cases of breast pseudoaneurysm have been reported in the literature, and most of these are related to previous interventional procedures. Pseudoaneurysm was suspected on real-time sonography and confirmed with color Doppler and spectral wave analysis, which revealed a characteristic to-and-fro pattern. Unlike previously reported cases, treatmentwith ultrasound-guided compression was successful.     

Penetrating and blunt abdominal trauma

This article is an overview of abdominal trauma relating to both penetrating and blunt mechanisms of injury. The incidence of abdominal injuries is discussed. Illustrated through case studies are interventions and treatment applicable to nursing practice. General principles of abdominal assessment are included. Anatomy and physiology of the different organ systems, as well as complications, is briefly overviewed. Differences between solid and hollow organs are reviewed. Pearls and pitfalls that impact nursing practice are presented for specific injuries.     

Hemorrhagic shock in the dog

Oxygen consumption, hemodynamics, and regional blood flow (with the radioactive microspheres technique) were determined in 12 anesthetized dogs subjected to hemorrhagic shock. The animals were kept in hypotension at 40 mmHg, until 15% of the maximum shed blood had been infused to keep arterial pressure stable, whereafter all the shed blood was retransfused. Cardiac output (CO) decreased to 33% and 25% of preshock values in survivors (S) and nonsurvivors (NS), respectively, and after retransfusion it was significantly higher in S. After retransfusion, NS showed a higher arterial pCO2 than S adding a respiratory component to the metabolic acidosis that occurred during and after hemorrhage. Blood flow to the brain was not impeded during shock, but as CO decreased the fraction delivered to the brain was increased 2.6-3.3-fold. Myocardial blood flow decreased to about 28% of preshock values immediately after hemorrhage, and increased to about 54% at the end of hemorrhage. After retransfusion S had a higher myocardial flow than NS. The flow to the gut paralleled the decrease in CO during hemorrhage and immediately after retransfusion NS exhibited an overperfusion in ileum and colon compared to the preshock values. Kidney blood flow fell progressively during the course of hypotension, similarly in S and NS. After retransfusion it was normalized in S but not in NS. The preshock flow to pancreas was significantly higher in S than in NS, but during and after shock the blood flow did not differ between S and NS.     

Tension pneumopericardium following blunt trauma

Tension pneumopericardium is uncommon after thoracic trauma and generally occurs following penetrating injury. Survivors of tension pneumopericardium secondary to blunt thoracic trauma are rare. We present the case of a 41 year old woman with multiple injuries after a high speed motor vehicle crash, who developed tension pneumopericardium shortly after endotracheal intubation and positive pressure ventilation. Aspiration of 110 mls of air from the pericardium in the Emergency Department produced a dramatic improvement in her condition and she was discharged 28 days later.     

Pneumoscrotum after blunt chest trauma

A case of pneumoscrotum after a suicide jump with blunt chest trauma and chest tube placement is reported. Pneumoscrotum itself has little clinical importance, but it is essential for the clinician to determine the origin of the air, and a careful search for the source of air is necessary. Three possible routes of air in the pneumoscrotum are reviewed. Many reported cases, including this case, had a cause distant from the pelvis: air dissected subcutaneously to the scrotum because of pneumothorax, tube thoracostomy, and air leak combined with ventilatory resuscitation efforts.     

Clinical review: Hemorrhagic shock

This review addresses the pathophysiology and treatment of hemorrhagic shock – a condition produced by rapid and significant loss of intravascular volume, which may lead sequentially to hemodynamic instability, decreases in oxygen delivery, decreased tissue perfusion, cellular hypoxia, organ damage, and death. Hemorrhagic shock can be rapidly fatal. The primary goals are to stop the bleeding and to restore circulating blood volume. Resuscitation may well depend on the estimated severity of hemorrhage. It now appears that patients with moderate hypotension from bleeding may benefit by delaying massive fluid resuscitation until they reach a definitive care facility. On the other hand, the use of intravenous fluids, crystalloids or colloids, and blood products can be life saving in those patients who are in severe hemorrhagic shock. The optimal method of resuscitation has not been clearly established. A hemoglobin level of 7–8 g/dl appears to be an appropriate threshold for transfusion in critically ill patients with no evidence of tissue hypoxia. However, maintaining a higher hemoglobin level of 10 g/dl is a reasonable goal in actively bleeding patients, the elderly, or individuals who are at risk for myocardial infarction. Moreover, hemoglobin concentration should not be the only therapeutic guide in actively bleeding patients. Instead, therapy should be aimed at restoring intravascular volume and adequate hemodynamic parameters.