PURPOSE: Prompt vascular access is crucial for resuscitating bleeding trauma casualties in prehospital settings but achieving peripheral intravenous (PIV) access can be challenging during hemorrhagic shock due to peripheral vessel collapse. Early intraosseous (IO) device use is suggested as an alternative. This study examines injury characteristics and factors linked to IO access requirements. METHODS: A registry-based cohort study from the Israel Defense Forces Trauma Registry (2010 - 2023) included trauma casualties receiving PIV or IO access prehospital. Casualties who had at least one documented PIV or IO access attempt were included, while those without vascular access were excluded. Casualties requiring both PIV and IO were classified in the IO group. Univariable logistic regression assessed the factors associated with IO access. Results were reported as odds ratios (OR) with 95% confidence intervals (CI), and significant difference was set at p < 0.05. RESULTS: Of 3462 casualties (86.3% male, the median age: 22 years), 3287 (94.9%) received PIV access and 175 (5.1%) had IO access attempts. In the IO group, 30.3% received freeze-dried plasma and 23.4% received low titer group O whole blood, significantly higher than that in the PIV group. Prehospital mortality was 35.0% in the IO group. Univariable analysis showed significant associations with IO access for increased PIV attempts (OR = 1.69; 95% CI: 1.34 - 2.13) and signs of profound shock (OR = 11.0; 95% CI: 5.5 - 23.3). CONCLUSION Profound shock signs are strongly linked to the need for IO access in prehospital settings with each successive PIV attempt increasing the likelihood of requiring IO conversion. IO access often accompanies low titer group O whole blood or freeze-dried plasma administration and higher prehospital mortality, indicating its use in emergent resuscitation situations. Early IO consideration is advised for trauma casualties with profound shock.
Humans ; Male ; Infusions, Intraosseous/methods* ; Female ; Registries ; Israel ; Emergency Medical Services/methods* ; Adult ; Young Adult ; Wounds and Injuries/mortality* ; Military Personnel ; Resuscitation/methods* ; Middle Aged ; Shock, Hemorrhagic/therapy* ; Cohort Studies

PURPOSE: SAM junctional tourniquet (SJT) has been applied to control junctional hemorrhage. However, there is limited information about its safety and efficacy when applied in the axilla. This study aims to investigate the effect of SJT on respiration when used in the axilla in a swine model. METHODS: Eighteen male Yorkshire swines, aged 6-month-old and weighing 55 - 72 kg, were randomized into 3 groups, with 6 in each. An axillary hemorrhage model was established by cutting a 2 mm transverse incision in the axillary artery. Hemorrhagic shock was induced by exsanguinating through the left carotid artery to achieve a controlled volume reduction of 30% of total blood volume. Vascular blocking bands were used to temporarily control axillary hemorrhage before SJT was applied. In Group I, the swine spontaneously breathed, while SJT was applied for 2 h with a pressure of 210 mmHg. In Group II, the swine were mechanically ventilated, and SJT was applied for the same duration and pressure as Group I. In Group III, the swine spontaneously breathed, but the axillary hemorrhage was controlled using vascular blocking bands without SJT compression. The amount of free blood loss was calculated in the axillary wound during the 2 h of hemostasis by SJT application or vascular blocking bands. After then, a temporary vascular shunt was performed in the 3 groups to achieve resuscitation. Pathophysiologic state of each swine was monitored for 1 h with an infusion of 400 mL of autologous whole blood and 500 mL of lactated ringer solution. T_b and T₀ represent the time points before and immediate after the 30% volume-controlled hemorrhagic shock, respectively. T₃₀, T₆₀, T₉₀ and T₁₂₀, denote 30, 60, 90, and 120 min after T₀ (hemostasis period), while T₁₅₀, and T₁₈₀ denote 150 and 180 min after T₀ (resuscitation period). The mean arterial pressure and heart rate were monitored through the right carotid artery catheter. Blood samples were collected at each time point for the analysis of blood gas, complete cell count, serum chemistry, standard coagulation tests, etc., and thromboelastography was conducted subsequently. Movement of the left hemidiaphragm was measured by ultrasonography at T_b and T₀ to assess respiration. Data were presented as mean ± standard deviation and analyzed using repeated measures of two-way analysis of variance with pairwise comparisons adjusted using the Bonferroni method. All statistical analyses were processed using GraphPad Prism software. RESULTS: Compared to T_b, a statistically significant increase in the left hemidiaphragm movement at T₀ was observed in Groups I and II (both p < 0.001). In Group III, the left hemidiaphragm movement remained unchanged (p = 0.660). Compared to Group I, mechanical ventilation in Group II significantly alleviated the effect of SJT application on the left hemidiaphragm movement (p < 0.001). Blood pressure and heart rate rapidly increased at T₀ in all three groups. Respiratory arrest suddenly occurred in Group I after T₁₂₀, which required immediate manual respiratory assistance. PaO₂ in Group I decreased significantly at T₁₂₀, accompanied by an increase in PaCO₂ (both p < 0.001 vs. Groups II and III). Other biochemical metabolic changes were similar among groups. However, in all 3 groups, lactate and potassium increased immediately after 1 min of resuscitation concurrent with a drop in pH. The swine in Group I exhibited the most severe hyperkalemia and metabolic acidosis. The coagulation function test did not show statistically significant differences among three groups at any time point. However, D-dimer levels showed a more than 16-fold increase from T₁₂₀ to T₁₈₀ in all groups. CONCLUSION In the swine model, SJT is effective in controlling axillary hemorrhage during both spontaneous breathing and mechanical ventilation. Mechanical ventilation is found to alleviate the restrictive effect of SJT on thoracic movement without affecting hemostatic efficiency. Therefore, mechanical ventilation could be necessary before SJT removal.
Male ; Animals ; Swine ; Shock, Hemorrhagic/therapy* ; Tourniquets ; Axilla ; Hemorrhage/therapy* ; Vascular Diseases ; Respiration

OBJECTIVE: To investigate the effects of Shenfu Injection (, SFI) on endothelial damage in a porcine model of hemorrhagic shock (HS). METHODS: After being bled to a mean arterial pressure of 40±3 mm Hg and held for 60 min, 32 pigs were treated with a venous injection of either shed blood (transfusion group), shed blood and saline (saline group), shed blood and SFI (SFI group) or without resuscitation (sham group). Venous blood samples were collected and analyzed at baseline and 0, 1, 2, 4, and 6 h after HS. Tumor necrosis factor-α (TNF-α), serum interleuking (IL)-6, and IL-10 levels were measured by enzyme-linked immunosorbent assay (ELISA); expressions of vascular cell adhesion molecule-1 (VCAM-1), intercellular adhesion molecule 1 (ICAM -1), von Willebrand factor (vWF), plasminogen activator inhibitor-1 (PAI-1) and Bcl-2, Bax, and caspase-3 proteins were determined by Western blot. RESULTS: The serum level of TNF-α in the SFI group was significantly lower than in the other groups at 0, 1, and 2 h after HS, while the level of IL-6 was lower at 4 and 6 h compared with the saline group (P<0.01 or P<0.05). The concentration of serum IL-10 was significantly higher in the SFI group than in the other groups at 0, 1, 4, and 6 h after HS (P<0.01). Western blot and immunohistochemistry of vascular tissue showed that the expression of caspase-3 was downregulated, and that of Bcl-2 and Bax was upregulated in the SFI group compared to other groups (P<0.05). CONCLUSION SFI attenuated endothelial injury in the porcine model of HS by inhibiting cell apoptosis, suppressing the formation of proinflammatory cytokines, and reducing endothelial activation.
Animals ; Caspase 3/metabolism* ; Drugs, Chinese Herbal ; Interleukin-10 ; Proto-Oncogene Proteins c-bcl-2/metabolism* ; Shock, Hemorrhagic/drug therapy* ; Swine ; Tumor Necrosis Factor-alpha/metabolism* ; bcl-2-Associated X Protein/metabolism*

PURPOSE: To summarize and analyze the early treatment of multiple injuries combined with severe pelvic fractures, especially focus on the hemostasis methods for severe pelvic fractures, so as to improve the successful rate of rescue for the fatal hemorrhagic shock caused by pelvic fractures. METHODS: A retrospective analysis was conducted in 68 cases of multiple trauma combined with severe pelvic fractures in recent 10 years (from Jan. 2006 to Dec. 2015). There were 57 males and 11 females. Their age ranged from 19 to 75 years, averaging 42 years. Causes of injury included traffic accidents in 34 cases (2 cases of truck rolling), high falling injuries in 17 cases, crashing injuries in 15 cases, steel cable wound in 1 case, and seat belt traction injury in 1 case. There were 31 cases of head injury, 11 cases of chest injury, 56 cases of abdominal and pelvic injuries, and 37 cases of spinal and limb injuries. Therapeutic methods included early anti-shock measures, surgical hemostasis based on internal iliac artery devasculization for pelvic hemorrhage, and early treatment for combined organ damage and complications included embolization and repair of the liver, spleen and kidney, splenectomy, nephrectomy, intestinal resection, colostomy, bladder ostomy, and urethral repair, etc. Patients in this series received blood transfusion volume of 1200-10,000 mL, with an average volume of 2850 mL. Postoperative follow-up ranged from 6 months to 1.5 years. RESULTS: The average score of ISS in this series was 38.6 points. 49 cases were successfully treated and the total survival rate was 72.1%. Totally 19 patients died (average ISS score 42.4), including 6 cases of hemorrhagic shock, 8 cases of brain injury, 1 case of cardiac injury, 2 cases of pulmonary infection, 1 case of pulmonary embolism, and 1 case of multiple organ failure. Postoperative complications included 1 case of urethral stricture (after secondary repair), 1 case of sexual dysfunction (combined with urethral rupture), 1 case of lower limb amputation (femoral artery thrombosis), and 18 cases of consumptive coagulopathy. CONCLUSION The early treatment of multiple injuries combined with severe pelvic fractures should focus on pelvic hemostasis. Massive bleeding-induced hemorrhagic shock is one of the main causes of poor prognosis. The technique of internal iliac artery devasculization including ligation and embolization can be used as an effective measure to stop or reduce bleeding. Consumptive coagulopathy is difficult to deal with, which should be detected and treated as soon as possible after surgical measures have been performed. The effect of using recombinant factor VII in treating consumptive coagulopathy is satisfactory.
Adult ; Embolization, Therapeutic ; methods ; Factor VII ; administration & dosage ; Female ; Fractures, Bone ; complications ; therapy ; Hemostasis, Surgical ; Humans ; Iliac Artery ; surgery ; Injury Severity Score ; Ligation ; Male ; Middle Aged ; Multiple Trauma ; complications ; therapy ; Pelvic Bones ; injuries ; Prognosis ; Recombinant Proteins ; administration & dosage ; Retrospective Studies ; Shock, Hemorrhagic ; etiology ; prevention & control ; Young Adult

Fluid Therapy ; Hemodynamics ; Humans ; Resuscitation ; Shock ; therapy ; Shock, Hemorrhagic ; Shock, Septic

Spontaneous rupture with internal bleeding of solid tumors has rarely been described at the time of diagnosis or during chemotherapy. This rare event must be regarded as a life threatening condition. In these emergency situations, control of hemorrhage, which is life-saving, can be achieved by transcatheter arterial embolization (TAE) and/or surgical resection. This report describes two infants presenting with acute hemorrhagic shock due to spontaneous tumor rupture of hepatoblastoma and neuroblastoma during chemotherapy. TAE successfully arrested the tumor bleeding and a visibly reduced the tumor size in both children. Spontaneous rupture of solid tumors occur infrequently in children, but is a life threatening situation. Careful monitoring for the occurrence of this rare event especially in very young children presenting with a large tumor mass.
Child ; Diagnosis ; Drug Therapy ; Emergencies ; Hemorrhage ; Hepatoblastoma ; Humans ; Infant ; Neuroblastoma ; Rupture ; Rupture, Spontaneous ; Shock, Hemorrhagic

BACKGROUNDThe expression of dendritic cell-specific intercellular adhesion molecule 3-grabbing nonintegrin (DC-SIGN) in renal tubular epithelial cells has been thought to be highly correlated with the occurrence of several kidney diseases, but whether it takes place in renal tissues during hemorrhagic shock (HS) is unknown. The present study aimed to investigate this phenomenon and the inhibitory effect of Vitamin C (VitC).

METHODSA Sprague-Dawley rat HS model was established in vivo in this study. The expression level and location of DC-SIGN were observed in kidneys. Also, the degree of histological damage, the concentrations of tumor necrosis factor-μ and interleukin-6 in the renal tissues, and the serum concentration of blood urea nitrogen and creatinine at different times (2-24 h) after HS (six rats in each group), with or without VitC treatment before resuscitation, were evaluated.

RESULTSHS induced DC-SIGN expression in rat tubular epithelial cells. The proinflammatory cytokine concentration, histological damage scores, and functional injury of kidneys had increased. All these phenomena induced by HS were relieved when the rats were treated with VitC before resuscitation.

CONCLUSIONSThe results of the present study illustrated that HS could induce tubular epithelial cells expressing DC-SIGN, and the levels of proinflammatory cytokines in the kidney tissues improved correspondingly. The results also indicated that VitC could suppress the DC-SIGN expression in the tubular epithelial cells induced by HS and alleviate the inflammation and functional injury in the kidney.

Animals ; Ascorbic Acid ; therapeutic use ; Blotting, Western ; Cell Adhesion Molecules ; metabolism ; Epithelial Cells ; drug effects ; metabolism ; pathology ; Immunohistochemistry ; Kidney Tubules ; drug effects ; metabolism ; pathology ; Lectins, C-Type ; metabolism ; Male ; Rats ; Rats, Sprague-Dawley ; Receptors, Cell Surface ; metabolism ; Shock, Hemorrhagic ; complications ; drug therapy ; metabolism

Fluid resuscitation, hemostasis, and transfusion is essential in care of hemorrhagic shock. Although estimation of the residual blood volume is crucial, the standard measuring methods are impractical or unsafe. Vital signs, central venous or pulmonary artery pressures are inaccurate. We hypothesized that the residual blood volume for acute, non-ongoing hemorrhage was calculable using serial hematocrit measurements and the volume of isotonic solution infused. Blood volume is the sum of volumes of red blood cells and plasma. For acute, non-ongoing hemorrhage, red blood cell volume would not change. A certain portion of the isotonic fluid would increase plasma volume. Mathematically, we suggest that the residual blood volume after acute, non-ongoing hemorrhage might be calculated as 0·25N/[(Hct1/Hct2)-1], where Hct1 and Hct2 are the initial and subsequent hematocrits, respectively, and N is the volume of isotonic solution infused. In vivo validation and modification is needed before clinical application of this model.
Blood Volume ; Hematocrit ; Humans ; Isotonic Solutions/*therapeutic use ; *Models, Theoretical ; Shock, Hemorrhagic/*prevention & control/*therapy

BACKGROUNDHemorrhagic shock (HS) results in myocardial contractile dysfunction. Studies showed that 17β-estradiol protects the myocardium against contractile dysfunction. The study investigated the cardioprotective effects of treatment with 17β-estradiol before resuscitation following 1 h of HS and resuscitation.

METHODSMale Sprague-Dawley rats were assigned to 2 sets of experimental protocols: Ex vivo and in vivo treatment and resuscitation. Each set had three experimental groups (n = 6 per group): Normotensive (N), HS and resuscitation (HS-R) and HS rats treated with 17β-estradiol (E) and resuscitated (HS-E-R). Rats were hemorrhaged over 60-min to reach a mean arterial blood pressure of 40 mmHg. In the ex vivo group, hearts were resuscitated by perfusion in the Langendorff system. In the 17β-estradiol treated group, 17β-estradiol 280 µg/kg was added for thefirst 5 min. Cardiac function was measured. Left ventricular generated pressure (LVGP) and +dP/dt were calculated. In the in vivo group, rats were treated with 17β-estradiol 280 µg/kg s.c. after 60-min HS. Resuscitation was performed in vivo by the reinfusion of the shed blood for 30-min to restore normotension.

RESULTSTreatment with 17β-estradiol before resuscitation in ex vivo treated and resuscitated isolated hearts and in the in vivo treated and resuscitated rats following HS improved myocardial contractile function. In the in vivo treated group, LVGP and +dP/dt max were significantly higher in 17β-estradiol treated rats compared to the untreated group (LVGP 136.40 ± 6.61 compared to 47.58 ± 17.55, and +dP/dt 661.85 ± 49.88 compared to 88.18 ± 0.85). Treatment with 17β-estradiol improved LVGP following HS.

CONCLUSIONSThe results indicate that treatment with 17β-estradiol before resuscitation following HS protects the myocardium against dysfunction.

Animals ; Estradiol ; therapeutic use ; Male ; Myocardial Contraction ; drug effects ; Myocardium ; pathology ; Rats ; Rats, Sprague-Dawley ; Resuscitation ; Shock, Hemorrhagic ; drug therapy

OBJECTIVE: To conduct signature analysis for splenic trauma in canines during hemorrhagic shock and resuscitation by contrast enhanced ultrasonography (CEUS). METHODS: Forty grade III-IV traumatic splenic lesions were established in 15 mongrel dogs. Hemorrhagic shock was induced in these animals by using the modified Wiggers's method. Animals in shock were then resuscitated with 6% hydroxyethyl starch. The features of splenic trauma during hemorrhagic shock or resuscitation were assessed by CEUS, which were compared with the data collected by contrast-enhanced computed tomography (CECT). Acoustic quantification of CEUS was performed to assess splenic blood perfusion in different stages. RESULTS: There was no significant difference in detection rate between CEUS and CECT during hemorrhagic shock and resuscitation. Before hemorrhagic shock, there were 40 traumatic bleeding lesions and 85% of them were revealed by CEUS (34/40). With the progress in shock, CEUS revealed that the numbers of tiny branches of splenic arteries were decreased, which became thinner with no active bleeding. After fluid resuscitation, rebleeding was occurred in 30 traumatic lesions, and 28 (93.3%) of them were captured by CEUS. CEUS could also visualize the changes in splenic perfusion in different stages. During the shock, the arrival time (AT), time to peak intensity (TTP), peak intensity (PI) were significantly lower and the washout time (WT) were significantly higher than those at other stages (P<0.01). CONCLUSION CEUS not only can dynamically monitor the changes in spleen traumatic hemorrhage and recurrent hemorrhage, but also can quantitatively study the changes in spleen blood perfusion in different stages.
Animals ; Contrast Media ; Disease Models, Animal ; Dogs ; Fluid Therapy ; Hemorrhage ; Hydroxyethyl Starch Derivatives ; therapeutic use ; Resuscitation ; Shock, Hemorrhagic ; pathology ; therapy ; Spleen ; diagnostic imaging ; Tomography, X-Ray Computed ; Ultrasonography