Massive transfusion.

Massive Transfusion is a part of Damage Control Resuscitation. The aim of transfusion therapy is to restore oxygen delivery to poorly perfused tissues and to treat the acute coagulopathy of trauma. The severity and complexity of modern injuries have led to the use of swift, protocol-driven care with the use of'Shock Packs' and management of metabolic complications. The proactive treatment of the coagulopathy has been termed Haemostatic Resuscitation. The delivery of this transfusion capability has required an increasingly sophisticated logistic and laboratory response. New operational capabilities have included cold chain solutions; laboratory management information systems; platelet apheresis and ROTEM. This investment in the massive transfusion capability has delivered rapid resuscitation. It has also enabled clinicians to direct individualised transfusion support following initial resuscitation i.e. goal directed therapy. Future technical solutions should further support the prehospital delivery of transfusion while addressing the logistic tail. However, the key to success is the knowledge and skills of frontline staff to deliver safe and appropriate blood transfusion.

A pre-hospital technique for controlling haemorrhage from traumatic perineal and high amputation injuries.

Perineal trauma resulting from the adaptive use of improvised explosive devices (IEDs) has become an increasingly common problem during current operational conflicts in Afghanistan. Control of haemorrhage from the perineum and high amputations is a particular challenge due to the bony anatomy, rich pelvic vascular supply and the difficulty in achieving haemostasis by direct pressure. In this article, the authors describe a potential pre-hospital solution for controlling haemorrhage from perineal and high amputation injuries.

Vascular access on the 21st century military battlefield.

Timely and appropriate access to the vascular circulation is critical in the management of 21st century battlefield trauma. It allows the administration of emergency drugs, analgesics and rapid replacement of blood volume. Methods used to gain access can include; the cannulation of peripheral and central veins, venous cut-down and intraosseus devices. This article reviews the current literature on the benefits and complications of each vascular access method. We conclude that intraosseus devices are best for quick access to the circulation, with central venous access via the subclavian route for large volume resuscitation and low complication rates. Military clinicians involved with the care of trauma patients either in Role 2 and 3 or as part of the medical emergency response team (MERT), must have the skill set to use these vascular access techniques by incorporating them into their core medical training.

Battlefield resuscitation.

PURPOSE OF REVIEW: To bring together in one review article, the most current and relevant evidence relating to military trauma resuscitation. RECENT FINDINGS: The main themes highlighted by this review are coagulopathy of trauma shock (CoTS), damage control resuscitation, haemostatic resuscitation, the management of massive transfusion, use of adjuvant drugs for haemostasis and use of an empiric massive transfusion protocol. SUMMARY: The review aims to educate the readership in recent advances in trauma practice, culminating in a novel empiric massive transfusion algorithm seamlessly guiding the clinician through the initial resuscitation stage resulting in reduced mortality, morbidity, coagulopathy and decreased overall blood product usage.

Flame acceleration and the development of detonation in fuel-oxygen mixtures at elevated temperatures and pressures.

Experimental measurements of the conditions required for the development of detonation in a 7 mm tube following ignition by a low energy spark are reported. There are then compared to previous experimental propagation limit criterion using theoretical predictions of detonation cell sizes based on a one-dimensional detonation length scale computed using a detailed chemical kinetic scheme. Technical difficulties precluded direct cell size measurements. Ethylene-oxygen and hydrogen-methane-oxygen mixtures were investigated as well as methane-ammonia-oxygen, at initial pressures and temperatures in the ranges 1-7 bar and 293-540 K, respectively. The likelihood of detonation in ethylene-air mixtures in 150 mm and 50mm pipes at ambient initial conditions is also discussed in relation to published cell width data.The results indicate that whilst detonation cell width predictions do not provide a quantitative measure of the conditions for which detonation may develop in a pipe of given diameter, for prescribed initial conditions, predicted detonation cell size data does provide useful qualitative guidance as to possible hazardous compositions, particularly if preliminary experimental safety testing is thought to be necessary.

Thromboembolic complications associated with factor VIIa administration.

BACKGROUND: Factor VIIa (FVIIa) is given to promote hemostasis in coagulopathic trauma patients at high risk for death. FVIIa is associated with thromboembolic complications, but the incidence is not known, nor is which patients are at risk. We examined our experience with FVIIa to better understand this issue. METHODS: Medical records of patients who received FVIIa from 2001 to 2006 were reviewed for evidence of thromboembolic events, including ischemic cardiovascular accident, myocardial ischemia or infarct, mesenteric infarct, peripheral arterial thromboembolism, deep venous thrombosis, or pulmonary embolus. Indication for FVIIa dosing, timing of complication, and clinical outcome were recorded. Each event was assessed by a panel of experienced clinicians to determine the contribution of FVIIa to the event and to patient outcome. RESULTS: Two hundred eighty-five medical records were reviewed. Twenty-seven patients (9.4%) had thromboembolic complications after administration of FVIIa. Nine events were thought to be highly related to FVIIa, and 10 of 14 deaths were, in part, caused by the thrombotic complication. Eighteen of the events, including all cardiovascular accidents and most cases of mesenteric ischemia, were attributed to a combination of FVIIa and a definable, high-energy vascular injury. CONCLUSION: FVIIa is a potent procoagulant, with the potential for adverse thromboembolic events in susceptible patients. Our experience suggests that caution should be exercised in administration of FVIIa to patients with arterial injuries. Injured mesenteric and cerebral vessels may be especially susceptible to thrombosis.

Concentrations of decabromodiphenyl ether in air from Southern Ontario: implications for particle-bound transport.

Atmospheric concentrations are reported for the main component of the brominated flame retardant decaBDE (BDE-209) in air samples collected from Southern Ontario for the period January 23-June 06, 2002. Levels ranged from below detection to 105pgm(-3) with virtually all of BDE-209 being trapped by the filter and thus deduced to be sorbed to aerosol particles. Thus, it is likely that the long-range atmospheric transport (LRAT) of BDE-209 is controlled by the transport characteristics of the aerosols. This conclusion that BDE-209 does not have the same potential for LRAT as other more volatile PBDEs is subject to possible complications arising from the uncertainties about the LRAT potential of aerosols.

First military use of activated Factor VII in an APC-III pelvic fracture.

A male soldier in shock with an APC-III pelvic fracture was flown to an Air Assault Surgical Group (AASG) of 16 Close Support Medical Regiment at Al Amarah in Iraq. A pelvic external fixator was applied and his condition stabilized. Ultrasound scanning (FAST) showed an absent bladder, and a spreading retroperitoneal haematoma combined with intra-abdominal, free blood. Unfortunately he continued to bleed and required transfusion with the unit's entire stock of type-specific blood. At emergency laparotomy, uncontrollable pelvic bleeding was encountered and the abdominal aorta required clamping above the iliac bifurcation. Branches of the right internal iliac artery were the source and this was ligated. Some bleeding continued post-operatively: administration of activated Factor VII was associated with a marked reduction in the oozing from his fixator pin-sites and an improvement in his pH from 7.1 to 7.3. In total, 25 units of blood were transfused, 8 of which were fresh whole blood donated by individual members of the AASG. The patient survived, returned to the UK, had his injuries reconstructed, and is currently undergoing rehabilitation. This case illustrates the benefits of forward resuscitation surgery in wartime and the need for a multidisciplinary approach to trauma care.

Polybrominated diphenyl ethers and selected organochlorine chemicals in grey seals (Halichoerus grypus) in the North Sea.

Blubber samples from grey seal (Halichoerus grypus) pups were collected in 1998 through to 2000. Twenty four newly weaned pups were sampled in November 1998, 13 of which were re-sampled during their first year of life, between March and December 1999, and an additional 48 and 25 samples (new cohorts) were obtained in 1999 (November-December) and 2000 (May-September) respectively. SimgaPBDE concentrations (sum of Di-HxBDEs) ranged from 45 to 1500 ng/g lipid, with a geometric mean of 290 ng/g lipid. BDE 47 dominated the congener profile, followed by BDEs 100, 99, 153 and 154. SimgaPCB concentrations (sum of 41 congeners) ranged from 100 to 93000 ng/g lipid, with a geometric mean of 4600 ng/g lipid, with CB congeners 153, 138 and 180 making up 84% of the total PCB concentrations. The predominant OC pesticides were p,p'-DDE (geometric mean=860 ng/g lipid, range=160-3800 ng/g lipid) and p,p'-DDT (geometric mean=120 ng/g lipid, range=30-670 ng/g lipid). No significant differences were found between males and females, probably due to the young age of the animals. Significant decreases (P<0.01 for PBDEs and P<0.05 for PCBs/OCs) were observed between newly weaned seals in 1998 and 1999, but not for the majority of juveniles in 1999 and 2000. Significant differences (P<0.01) were also found between the different seasons in 1999 newly weaned and juvenile seals, reflecting changes in blubber mass.

Use and validation of novel snow samplers for hydrophobic, semi-volatile organic compounds (SVOCs).

Two novel gas-tight snow samplers (snow-can and snow-tube) are presented and the performance of the snow-can in a field trial was assessed. The methodology for the sampling, extraction and analysis of persistent organic pollutants (POPs) are detailed. These samplers allow the various components of a snow sample to be analysed separately; these included the meltwater (MW), particulate matter (GFF) and vapour in the headspace (HS). Snow samples collected on the Punta Indren glacier in the Italian Alps revealed the occurrence of polychlorinated biphenyls (PCBs), polycyclic aromatic hydrocarbons (PAHs) and organochlorine pesticides (OC). Replicate samples of the same snow type were undertaken as a test of sampling precision. Relative standard deviations (RSDs) for SigmaPCBs and SigmaPAHs were approximately 30% and approximately 35% respectively. The lowest precision was found for the particle-laden snow, notably for the heavier PCB homologues. For the chlorinated compounds, the pesticides lindane and endosulfan-I had the highest levels in snow, with mean concentrations of 402 and 103 pgl(-1) (snow meltwater) respectively. The vapour present in the headspace (HS) comprised a minor component of a collected sample for all compounds, but HS concentrations for three lighter PAHs gave good agreement with those calculated based on their dimensionless Henry's law constants. This suggests that volatilisation during melting of aged snow-can be reasonably predicted with knowledge of the temperature-dependent Henry's law constant.

Atmospheric emissions of polybrominated diphenyl ethers and other persistent organic pollutants during a major anthropogenic combustion event.

Air samples were taken for the analysis of persistent organic pollutants before, during, and after the national U.K. "Bonfire Festival" in November 2000. As expected, ambient levels of polynuclear aromatic hydrocarbons (PAHs) increased sharply in response to the widespread diffusive combustion processes that occurred at the time. Polybrominated diphenyl ethers (PBDEs) also increased at the suburban sampling location, to a greater extent than the PAHs. The rise and fall in PBDE concentrations was rapid, coinciding closely with the PAH "combustion markers". These data provide evidence for a novel mechanism responsible for dissipation of PBDEs into the environment. It is hypothesized that products treated with the penta-BDE product--notably household furnishing foams and textiles--have been subject to (unsanctioned) burning on private bonfires; even if the majority of the PBDE burden of such products is debrominated/broken down in the fires, it is shown that only small amounts of the total "stock" of penta product need be emitted to generate the concentrations detected. The mixture of PBDEs in the air during the Bonfire Festival was enriched in higher brominated congeners (e.g., BDE-99, -153, and -154) compared to that in background air. Estimates are made of the masses of compound classes that may have been emitted to the atmosphere during the festival.

Air-surface exchange of polybrominated diphenyl ethers and polychlorinated biphenyls.

Air and leaf-litter samples were collected from a rural site in southern Ontario under meteorologically stable conditions in the early spring, prior to bud burst, over a three-day period to measure the simultaneous diurnal variations in polybrominated diphenyl ethers (PBDEs) and polychlorinated biphenyls (PCBs). PBDEs are used in a wide range of commercial products as flame retardants and are being assessed internationally as potential persistent organic pollutants. Total PBDE concentrations in the air ranged between 88 and 1250 pg m(-3), and were dominated primarily by the lighter congeners PBDEs 17, 28, and 47, and concentrations of total PCBs ranged between 96 and 950 pg m(-3), and were dominated by the lower chlorinated (tri- to tetra-) congeners. Slopes of Clausius-Clapeyron plots indicate that both PCBs and PBDEs are experiencing active air-surface exchange. Fugacities were estimated from concentrations in the air and leaf-litter and suggest near equilibrium conditions. Following the three-day intensive sampling period, 40 air samples were collected at 24-hour intervals in an attempt to evaluate the effect of bud burst on atmospheric concentrations. Total PBDE concentrations in the daily air samples ranged between 10 and 230 pg m(-3), and were dominated by the lighter congeners PBDE 17, 28, and 47, whereas concentrations of total PCBs ranged between 30 and 450 pg m(-3) during this period. It is hypothesized thatthe high PBDE concentrations observed at the beginning of the sampling period are the result of an "early spring pulse" in which PBDEs deposited in the snowpack over the winter are released with snowmelt, resulting in elevated concentrations in the surface and air. Later in the sampling period, following bud burst, PBDE concentrations in air fell to 10 to 20 pg m(-3), possibly due to the high sorption capacity of this freshly emerging foliage compartment.

Grass-air exchange of polychlorinated biphenyls.

Three field experiments were performed to assess the clearance, uptake, and exchange kinetics of polychlorinated biphenyls (PCBs) between grass and the atmosphere using mixed- and single-species grass (Holcus lanatus). In the clearance experiment, the grass was artificially contaminated by equilibration with diluted Aroclor vapor then exposed to field air, and the rates of depletion were monitored by sampling at regular intervals to determine clearance rate constants. In the uptake experiment, the uptake of PCBs from the ambient atmosphere was followed in growing grass at ambient concentrations for 3 and 6 weeks by analysis of segmented samples along the length of the sward. In the third experiment, diurnal temperature-driven changes in grass concentrations were measured. The results indicate that the grass is behaving as a two-compartment system: (1) a fast-exchanging surface adsorption site with a response time of hours and a capacity essentially independent of K(OA), the octanol-air partition coefficient and (2) a slow responding site with a response time of weeks, the capacity of which is related to K(OA). The kinetic and equilibrium phenomena involved in grass-air exchange are thus complex and are not adequately described by simple first-order rate constants and equilibrium partitioning coefficients.

Behavior of sewage sludge-derived PAHs on pasture.

A field experiment was set up to investigate the retention of PAHs by pasture grass following sludge application. In addition to information on compound-specific loss rates, the influence of meteorological variables and sludge-pasture contact time on the weathering process were investigated. The rates of loss were compound specific with half-lives ranging from < 1 to 10 d. The lighter PAHs were rapidly lost from the grass surface primarily by volatilization. For the intermediate and heavier PAHs, loss was slower with rain playing an important role in the weathering process. Growth dilution was also important in reducing the contaminant levels in the grass. The effect of sludge-pasture contact time prior to weathering by rain on the residual levels remains unclear. In terms of risk of exposure, there is the potential for persistent organic contaminants to be introduced into the grazing animal food chain if sewage sludge is applied to pasture land.

Seasonal and species differences in the air--pasture transfer of PAHs.

A field plot was established at a semirural site in the U.K. to investigate the atmospheric transfer of PAHs to different pasture species over the whole growing season. The PAHs displayed a range of partitioning behaviors in the atmosphere from exclusively gas phase to exclusively particle bound, resulting in different modes of deposition to the plant surface. The different pasture species had different plant and sward characteristics, e.g., leaf morphologies, yields, etc. For the majority of PAHs, the plant species displayed a seasonality in concentrations, with concentrations being higher in the winter than in the summer. For the lighter PAHs, this seasonality was absent with soil outgassing and/or summer sources of PAHs being implicated. Air-plant transfer factors (scavenging coefficients, with units m3/g dw) typically ranged between 4 and 52 during the summer, increasing to 8-88 during winter. Despite different plant and sward characteristics, the mixtures and concentrations of PAHs were similar for all the plant species. This indicates that there was little difference in the interception and retention behavior of the gas- and particle-phase PAHs. The implications of this for food chain transfer and air-vegetation modeling are discussed.

The global distribution of PCBs and organochlorine pesticides in butter.

In this study we explored the use of butter as a sampling matrix to reflect the regional and global scale distribution of PCBs and selected organochlorine pesticides/metabolites in air. This was because persistent organic pollutants (POPs) concentrate in dairy fats, where concentrations are controlled by feed intake (primarily from pasture/silage), which is in turn primarily controlled by atmospheric deposition. Butter sigmaPCB concentrations varied by a factor of approximately 60 in 63 samples from 23 countries. They were highest in European and North American butter and lowest in southern hemisphere (Australian, New Zealand) samples, consistent with known patterns of historical global usage and estimated emissions. Concentrations in butter reflected differences in the propensity of PCB congeners to undergo long range atmospheric transport from global source regions to remote areas and the relatively even distribution of HCB in the global atmosphere. Concentrations of p,p'-DDT, p,p'-DDE, and HCH isomers all varied over many orders of magnitude in the butter samples, with highest levels in areas of current use (e.g. India and south/central America for DDT; India, China, and Spain for HCH). We conclude that butter is sensitive to local, regional, and global scale spatial and temporal atmospheric trends of many POPs and may therefore provide a useful sampling medium for monitoring purposes. However, to improve the quantitative information derived on air concentrations requires an awareness of climatic and livestock management factors which influence air-milk fat transfer processes.

Methods for the analysis of PCBs in human food, faeces and serum.

A method was developed to determine trace concentrations of a range of individual PCB congeners in biological samples (serum, food and faeces) using GC-MS, to prepare a mass balance of PCBs in humans. A simple method for the analysis of PCBs in human serum, which excluded an extraction step, was first employed. Results indicated that the recoveries of 13C12 PCB spikes were variable. A soxhlet extraction step was added and was found to be efficient and reproducible. A quality control routine and method validation results are presented. In batch tests of the methods presented it was found that the serum analysis method gave within batch mean 13C12 spike recoveries of 98-120% and standard deviations between 6 and 20%. The food/faeces analysis method gave within-batch mean 13C12 spike recoveries of 88-100%, and within batch standard deviations between 4 and 12%. The batch to batch mean recovery for serum analysis was 100%, with an RSD of 9% for high spikes and 10% for low spikes. For food/faeces analysis the batch to batch average recovery was 110%, with an RSD of 5% for high spikes and 9% for low spikes.