1/18. Reversal by vasopressin of intractable hypotension in the late phase of hemorrhagic shock.BACKGROUND: Hypovolemic shock of marked severity and duration may progress to cardiovascular collapse unresponsive to volume replacement and drug intervention. On the basis of clinical observations, we investigated the action of vasopressin in an animal model of this condition. methods AND RESULTS: In 7 dogs, prolonged hemorrhagic shock (mean arterial pressure [MAP] of approximately 40 mm Hg) was induced by exsanguination into a reservoir. After approximately 30 minutes, progressive reinfusion was needed to maintain MAP at approximately 40 mm Hg, and by approximately 1 hour, despite complete restoration of blood volume, the administration of norepinephrine approximately 3 micrograms . kg(-1). min(-1) was required to maintain this pressure. At this moment, administration of vasopressin 1 to 4 mU. kg(-1). min(-1) increased MAP from 39 /-6 to 128 /-9 mm Hg (P<0.001), primarily because of peripheral vasoconstriction. In 3 dogs subjected to similar prolonged hemorrhagic shock, angiotensin ii 180 ng. kg(-1). min(-1) had only a marginal effect on MAP (45 /-12 to 49 /-15 mm Hg). plasma vasopressin was markedly elevated during acute hemorrhage but fell from 319 /-66 to 29 /-9 pg/mL before administration of vasopressin (P<0.01). CONCLUSIONS: Vasopressin is a uniquely effective pressor in the irreversible phase of hemorrhagic shock unresponsive to volume replacement and catecholamine vasopressors. Vasopressin deficiency may contribute to the pathogenesis of this condition.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
2/18. Use of the intra-aortic balloon pump to stop gastrointestinal bleeding.Temporary aortic occlusion can be lifesaving in selected conditions. We describe the unorthodox use of an intra-aortic balloon pump without counterpulsation to achieve temporary vascular control in a patient with shock caused by rapid upper gastrointestinal bleeding. The technique of aortic balloon occlusion has been reported in several clinical circumstances, primarily trauma. However, its use to increase blood pressure and gain time for resuscitation before laparotomy for catastrophic gastrointestinal bleeding has not previously been described.- - - - - - - - - - ranking = 0.5keywords = pressure (Clic here for more details about this article) |
3/18. A technique of anaesthesia in haemorrhagic shock. Illustrative case histories and a discussion.The anaesthetic management of patients in haemorrhagic shock is described. The principles are those of initial resuscitation with electrolyte solutions and alleviation of metabolic acidosis, combined with early induction of anaesthesia to permit control of bleeding as soon as possible. The anaesthetic technique depends on pre-oxygenation, intravenous anaesthesia, muscular relaxation and ventilation with pure oxygen. Earlier cases were induced with thiopentone and maintained with intermittent suxamethonium, but intravenous ketamine was later employed for induction and intramuscular ketamine for maintenance; this use of ketamine is now the author's method of choice. The use of a central venous pressure line connected to a cannula in the internal jugular vein is recommended.- - - - - - - - - - ranking = 0.5keywords = pressure (Clic here for more details about this article) |
4/18. tetany following resuscitation after abruptio placentae.BACKGROUND: serum ionized calcium and magnesium are normally decreased during later stages of pregnancy. A further rapid decline may be caused by the rapid infusion of blood bank products in which citrate is used as an anticoagulant/preservative. tetany, as reported here, may be precipitated by such infusions.CASE: A gravid woman presented in hemorrhagic shock due to abruptio placentae. Rapid infusion of packed red blood cells and fresh frozen plasma precipitated signs of tetany, muscle rigidity, posturing, high airway pressure during mechanical ventilation, etc. Ionized calcium and magnesium blood levels were very low (0.58 mmol/L and 1.0 mg/dL, respectively), but responded to rapid electrolyte administration.CONCLUSION: Binding of calcium and magnesium by citrate may lead to hypo-ionized calcemic and hypomagnesemic tetany after rapid replacement of blood products in the pregnant patient. This consequence is worsened when extreme alkalemia due to respiratory or metabolic causes is also present.- - - - - - - - - - ranking = 0.5keywords = pressure (Clic here for more details about this article) |
5/18. survival with an arterial pH of 6.57 following major trauma with exsanguinating haemorrhage associated with traumatic amputation.We report the survival of a multiply injured patient with exanguinating haemorrhage and an arterial pH of 6.5, following a road vehicle crash. The previously healthy 38 years old male driver veered off the motorway and collided with a tree. The ambulance arrived at the scene 9 min after being called by an eyewitness and, following rapid extrication from the wreckage; the patient arrived in hospital 27 min later (with a GCS of 6), and was immediately intubated. The patient had suffered near-complete amputation of the left leg at upper femoral shaft level, along with multiple distal fractures and open wounds. He also sustained a head injury and closed displaced fractures of left radius and ulna. The patient received 2 l of crystalloids in the pre-hospital phase. Once in hospital the haemorrhage was controlled with a pressure dressing and intra-venous fluids were kept to a minimum until he was taken promptly to theatre. His initial arterial blood sample revealed a pH of 6.57, pCo(2) of 9.18 kPa, a pO(2) of 70.11 kPa and a base excess of -27.5 mmol l(-1). The co-oximeter Hb was 5.8 g dl(-1). Haemorrhage was controlled in theatre where he was transfused a total of 30 U of blood, 1 pack of platelets, 12 U of fresh frozen plasma, 3.5 l of crystalloids and 1.5 l of colloid. sodium bicarbonate was administered three times. He subsequently remained ventilated in intensive care unit (ICU). Over the following week he survived sepsis, disseminated intravascular coagulation and myoglobinuria (with transient renal failure) attributable to rhabdomyolysis secondary to muscle necrosis. He later underwent diversion colostomy and disarticulating amputation of the left femur after several debridements. After 6 weeks on ICU he made an excellent recovery will full return of his mental abilities. In this case, the serial arterial blood samples obtained were reliable. The lactic acidosis observed was the result of profound tissue hypo-perfusion and its rate of clearance seems to have greater prognostic value than its peak or initial value. Several factors may have contributed to the patient's survival: rapid retrieval from the scene; early intubation with excellent subsequent oxygenation (thus avoiding the dangerous combination of hypoxia and acidosis with synergistic influence on cardiac depression) and limited initial fluid resuscitation in the emergency department with prompt surgical intervention and vigorous restoration of organ perfusion after surgical haemostasis. Immediate operative haemostasis, coupled with restricted fluid administration beforehand and vigorous restoration of organ perfusion afterwards is now replacing the old resuscitation paradigm. Perhaps this shift in practice has helped this patient to survive.- - - - - - - - - - ranking = 0.5keywords = pressure (Clic here for more details about this article) |
6/18. Successful resuscitation by emergency room thoracotomy in a patient in agonal state with hemorrhagic shock resulting from penetrating cardiac injury.A 23-year-old male patient, who was stabbed in the left chest at the fourth intercostal space leaving a 4-cm wound, was in agonal state with blood pressure of 0/0 kPa when admitted. The patient underwent emergency room thoractomy on stretcher through the left fourth intercostal anterior lateral incision 16 min after injury. The exploration revealed 2 500 ml blood in the plural cavity, 4-cm wound in the pericardium, 2-cm wound in the right ventricle of the heart without asystole, and 5-cm wound in the left upper lobe of the lung. Within 4 min the wound in the heart was sutured with the pericardium as the backing. The patient was discharged with full recovery 8 d after injury.- - - - - - - - - - ranking = 0.5keywords = pressure (Clic here for more details about this article) |
7/18. Anti-shock garment provides resuscitation and haemostasis for obstetric haemorrhage.OBJECTIVE: To evaluate the feasibility, safety and effectiveness of the non-pneumatic anti-shock garment for resuscitation and haemostasis following obstetric haemorrhage resulting in severe shock. DESIGN: During a six-week period, the author served a locum tenens as the obstetrician consultant for the Memorial Christian Hospital, Sialkot, pakistan. All women who suffered from severe obstetric haemorrhage were managed with the anti-shock garment as the first intervention. The data for this report were collected from hospital chart review. SETTING: Sialkot is a city of about three million and Memorial Christian Hospital is one of two major obstetric hospitals. There is no blood bank at Memorial Christian Hospital or elsewhere in Sialkot. The Memorial Christian Hospital laboratory is able to draw donor blood, type and cross match blood, and process it for transfusion 24 hours per day. population: During the six weeks of this study, in June and July 2001, there were 764 deliveries and 34 other admissions within a week following deliveries outside the hospital. Seven women with obstetric haemorrhage who developed severe shock were managed with the anti-shock garment. One woman, who was later found to have mitral stenosis, developed dyspnea upon placement of the anti-shock garment and therefore it was removed within 5 minutes. This report concerns the six women who were able to tolerate the anti-shock garment without untoward symptoms. methods: As soon as severe shock was recognised in the hospital, the anti-shock garment was placed. Crystalloid solutions were given intravenously over the first hour at a rate of 1500 mL per estimated litre of blood loss, then at a maintenance rate of 150 mL/hour. vital signs every 15 to 30 minutes, hourly urine output and intermittent oxygen saturation were used to monitor patients during the use of the anti-shock garment. When sufficient blood transfusion had been given to restore the haemoglobin to >7 g/dL, the anti-shock garment was removed in segments at 15-minute intervals with documentation of vital signs before removal of each subsequent portion. MAIN OUTCOME MEASURES: Restoration of mean arterial pressure of 70 mmHg and clearing of sensorium were considered as signs of effective resuscitation. Haemorrhage was considered controlled if the blood loss was less than 25 mL/hour. morbidity included any complications noted in the medical chart. RESULTS: Restoration of blood pressure and improvement of mental status occurred within 5 minutes in two patients who were pulseless and three who were unconscious or confused. All patients had improvement of mean arterial pressure to greater than 70 mmHg within 5 minutes. Duration of anti-shock garment use ranged from 12 to 36 hours and none of the six women had significant further bleeding while the anti-shock garment was in place. patients were comfortable during use of the anti-shock garment and no adverse effects were noted apart from a transient decrease in urine output. CONCLUSIONS: The anti-shock garment rapidly restored vital signs in women with severe obstetric shock. There was no further haemorrhage during or after anti-shock garment use and the women experienced no subsequent morbidity. A prospective randomised study of the anti-shock garment for management of obstetric haemorrhage is needed to further document these observations.- - - - - - - - - - ranking = 1.5keywords = pressure (Clic here for more details about this article) |
8/18. Small volume resuscitation with 7.5% hypertonic saline solution--treatment of haemorrhagic shock in the tropics.Rapid intravenous injection of 4 mL/kg body weight of a 7.5% hypertonic sodium chloride solution immediately increases intravascular osmotic pressure and intravascular volume after haemorrhage. This 'small volume resuscitation' rapidly improves blood pressure and microcirculatory perfusion in patients with hypovolaemic shock after large blood losses. Pathophysiological findings as well as practical application approaches are described. Small volume resuscitation is an effective and economic method in the first-line treatment of acute haemorrhagic shock.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
9/18. Dynamic changes in regional CBF, intraventricular pressure, CSF pH and lactate levels during the acute phase of head injury.The authors measured regional cerebral 133xenon (133Xe) blood flow (rCBF), intraventricular pressure (IVP), cerebrospinal fluid (CSF) pH and lactate, systemic arterial blood pressure (SAP), and arterial blood gases during the acute phase in 23 comatose patients with severe head injuries. The IVP was kept below 45 mm Hg. The rCBF was measured repeatedly, and the response to induced hypertension and hyperventilation was tested. Most patients had reduced rCBF. No correlation was found between average CBF and clinical condition, and neither global nor regional ischemia contributed significantly to the reduced brain function. No correlation was found between CBF and IVP or CBF and cerebral perfusion pressure (CPP). The CSF lactate was elevated significantly in patients with brain-stem lesions, but not in patients with "pure" cortical lesiosn. The 133Xe clearance curves from areas of severe cortical lesions had very fast initial components called tissue peaks. The tissue peak areas correlated with areas of early veins in the angiograms, indicating a state of relative hyperemia, referred to as tissue-peak hyperemia. Tissue-peak hyperemia was found in all patients with cortical laceration or severe contusion but not in patients with brain-stem lesions without such cortical lesions. The peaks increased in number during clinical deterioration and disappeared during improvement. They could be provoked by induced hypertension and disappeared during hyperventilation. The changes in the tissue-peak areas appeared to be related to the clinical course of the cortical lesion.- - - - - - - - - - ranking = 3.5keywords = pressure (Clic here for more details about this article) |
10/18. Isolated peliosis of the spleen: report of 2 autopsy cases.Isolated peliosis of the spleen, characterized by the gross appearance of multiple cystlike, blood-filled cavities on cut surfaces of the organ, is a very rare pathologic entity that has been reported in 33 cases to date. We present 2 additional cases of isolated peliosis of the spleen observed at autopsy and confirmed by histology. In both cases investigated, cirrhosis of the liver was present. We hypothesize that local microcirculatory disturbances manifesting under altered local intravascular pressure conditions in the spleen may, at least to a certain degree, be responsible for the peliosis-associated vascular lesions. For the forensic pathologist, isolated peliosis of the spleen represents more than just another morphologic curiosity. The significance of peliosis lienalis lies in the potential of (1) overlooking the correct diagnosis as the cause of a spontaneous splenic rupture with intraabdominal hemorrhage, thus leading to the false conclusion of a violent death; and (2) misinterpreting the macromorphological appearance of this rare disease, also in the absence of splenic rupture, as a result of blunt force trauma.- - - - - - - - - - ranking = 0.5keywords = pressure (Clic here for more details about this article) |
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