Blood, 13 november 2014 - volume 124, number 20

Abstract: 
Massive hemorrhage is associated with coagulopathy and high mortality. The transfusion guidelines up to 2006 recommended that resuscitation of massive hemorrhage should occur in successive steps using crystalloids, colloids, and red blood cells (RBCs) in the early phase and plasma and platelets in the late phase. With the introduction of the cell-based model of hemostasis in the mid-1990s, our understanding of the hemostatic process and of coagulopathy has improved. This has contributed to a change in resuscitation strategy and transfusion therapy of massive hemorrhage along with an acceptance of the adequacy of whole blood hemostatic tests to monitor these patients. Thus, in 2005, a strategy aiming at avoiding coagulopathy by proactive resuscitation with blood products in a balanced ratio of RBC:plasma:platelets was introduced, and this has been reported to be associated with reduced mortality in observational studies. Concurrently, whole blood viscoelastic hemostatic assays have gained acceptance by allowing a rapid and timely identification of coagulopathy along with enabling an individualized, goal-directed transfusion therapy. These strategies joined together seem beneficial for patient outcome, although final evidence on outcome from randomized controlled trials are lacking. We present how we in Copenhagen and Houston, today, manage patients with massive hemorrhage.

Emerg Med J 2005;22:8–16

This review examines the present understanding of tension pneumothorax and produces recommendations for improving the diagnostic and treatment decision process.

Tension pneumothorax (TPT) is an uncommon disease with a malignant course leading to death if untreated. It is most commonly encountered in prehospital trauma care, emergency departments, and intensive care units (ICUs). Resuscitation and trauma courses usually illustrate a patient in extremis and assume that the clinical diagnosis is straightforward and the response to needle chest decompression is rapid and reliable. However, this might not be the case in real life. Texts differ when describing the diagnostic symptoms and signs and there are several case reports of diagnostic difficulty or missed diagnosis because of an absence of “classic” signs. Lack of chest signs along with poor correlation between the signs present and those picked up by experienced physicians have been specifically noted. There have also been multiple reports of ineffective needle decompression with adequate treatment only being achieved with tube thoracostomy.