Index

A

ABCs. See Airway-breathing-circulation format

Actin, testing for caspase-specific degradation fragments from, 43

Acute hemorrhagic shock, pathophysiology of, 4, 19-44

''Acute respiratory distress syndrome,''15

Acute respiratory failure, 50

Adenosine, 74

Adenosine diphosphate (ADP)

phosphorylation of, 26

release of, 52

Adenosine triphosphate (ATP)

depletion during ischemia, 26, 55

production of, 26, 55

Adhesion molecules, intracellular, 58

Adrenergic downregulation, 37

Advanced Trauma Life Support® (ATLS® course, 100, 102

Aeromedical evacuation, prompt, 106

Airway

and breathing, 104-106

obstruction of, 10

securing, 99, 101, 104-105

Airway-breathing-circulation format, 103

Albumin-containing solutions

advantages of, 60

as a resuscitation fluid, 39, 51, 60

Altered physiologic states, 93

American College of Emergency Physicians (ACEP), 102

American College of Surgeons, 102, 118-119

Committee on Trauma, 39

Analgesia, administering, 101

Anemia, 51

Anesthesia

cardiovascular effects of, 114

depressant effects of, 114-115

inhalant, 114

intravenous, 114

role in hemorrhagic shock, 110, 114-115

Animal models, 3, 109-112

canine, 109-110, 112

primate, 110, 112

rodent, 110-112

shortcomings of, 112-113, 122

standardizing. 3

swine, 109, 111

value of, 112

Antibiotics, administering. 101

Antibodies, monoclonal, 89

Antioxidants, adding to lactated Ringer's solution, 3, 76



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Index A ABCs. See Airway-breathing-circulation format Actin, testing for caspase-specific degradation fragments from, 43 Acute hemorrhagic shock, pathophysiology of, 4, 19-44 ''Acute respiratory distress syndrome,''15 Acute respiratory failure, 50 Adenosine, 74 Adenosine diphosphate (ADP) phosphorylation of, 26 release of, 52 Adenosine triphosphate (ATP) depletion during ischemia, 26, 55 production of, 26, 55 Adhesion molecules, intracellular, 58 Adrenergic downregulation, 37 Advanced Trauma Life Support® (ATLS® course, 100, 102 Aeromedical evacuation, prompt, 106 Airway and breathing, 104-106 obstruction of, 10 securing, 99, 101, 104-105 Airway-breathing-circulation format, 103 Albumin-containing solutions advantages of, 60 as a resuscitation fluid, 39, 51, 60 Altered physiologic states, 93 American College of Emergency Physicians (ACEP), 102 American College of Surgeons, 102, 118-119 Committee on Trauma, 39 Analgesia, administering, 101 Anemia, 51 Anesthesia cardiovascular effects of, 114 depressant effects of, 114-115 inhalant, 114 intravenous, 114 role in hemorrhagic shock, 110, 114-115 Animal models, 3, 109-112 canine, 109-110, 112 primate, 110, 112 rodent, 110-112 shortcomings of, 112-113, 122 standardizing. 3 swine, 109, 111 value of, 112 Antibiotics, administering. 101 Antibodies, monoclonal, 89 Antioxidants, adding to lactated Ringer's solution, 3, 76

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Antioxidant strategies, 86-87 endogenous, 54 APACHE scoring system, 118 Apoptotic signals, originating from cellular organelles, 35 Apoptosis, 29-36, 65-66 complexity of system for, 36 cytoplasmic, 30 defined, 29-30 developmental, 30 plasmalemma receptor-induced, 30 Aptotic internucleosomal DNA fragmentation, 35 Arachidonate, oxidative metabolism of, 27 ARDS. See Acute respiratory distress syndrome Arginine administration, 57 Ascorbic acid, 87 Assessment methodologies, 118 Asymmetric battlefields, 10 ATLS®. See Advanced Trauma Life Support® course Auto-tyrosine phosphorylation, 36 B Bacterial diseases, transmitted by transfusions, 41 Basic tactical casualty management plan, for Special Operations forces, 101 Basic Trauma Life Support (BTLS) course, 102 Battlefield bulk of solutions that must be transported onto, 51 expected condition of combatants on, 98 ideal solution for fluid resuscitation on, 98 limits of care on, 98-99, 102 resuscitation needs on, 98-99 salvageable casualties on, 9, 98 Battlefield injuries compared with inner city, 15 modeling, 113 Bleeding. See Blood loss Blood, citrate-preserved, 38 Blood banking, 38 Blood hemoglobin concentration. acute isovolemic reduction of, 80-81 Blood loss, 9-10, 100-101 handling on battlefield, 2 intraoperative, 29, 42 molecular and cellular responses to, 4 rates of, 113 Blood plasma, 14 drawbacks of, 60 Blood pressure, 113 Blood substitutes, 41-42. See also Oxygen therapeutics Blood transfusions, 38 alternatives to, 41-42 risks of, 41 "Boutique fluids," 79 Brain injury, 10 compression, 29 Brain ischemia, 33 free fatty acids released during. 27 reducing, 85 salvaging vulnerable neurons after, 34 Breathing and airway, 101, 104-106 C Calpain-specific degradation fragments of spectrin, testing for, 43 Cancer and Leukemia Group B, 121 Cannon, Walter, 13-14 Capillary leak syndrome, 15 Cardiac myocytes, ischemic death of, 30 Cardiogenic shock, defined, 20-21 Cardiopulmonary resuscitation, 101 Cardiovascular collapse, 114 Carolina Rinse solution, 73-74 Caspases mediating degradation of eIF4G, 33 prototypic, 32 receptor-mediated activation of, 30 Caspase-specific degradation fragments from actin, testing for, 43 Catalase, 82, 86 Catecholamines, 111-112 CD 18 cells, altering, 111 Cell hypoxia, 20

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Cellular derangements, accompanying traumatic shock, 4 Cellular organelles, apoptic signals originating from, 35 Cellular responses to shock, 25-28 altered energy metabolism, 25-26 ion compartmentalization, 26-27 lipid metabolism, 27 radical production and metabolism, 27-28 Cellular responsiveness to growth factors, alterations in, 36-38 Central nervous system inhibiting insulin transport into, 37 injuries to, 9-10 protecting, 85 Circulatory support, 99 Citrate-preserved blood, 38, 40 Civilian data applicability of, 121 on trauma, 98, 123 Civilian trauma centers, 121-122 Clinically significant function, defined, 116 Clinical practice guidelines, 61 Clinical trauma. See Trauma Clinical trials applicability of civilian data, 121 defined, 116 endpoints and indications of, 116-120 heterogeneous subject populations, 120 of hypertonic saline-dextran (HSD), 71-73 informed consent, 120 role in developing therapies, 115-116 in trauma centers, 121-122 unique problems of, 3, 120-121 Clotting, 51 Clotting factors, alterations in amount of, 40 Coagulation disseminated intravascular, 42-43 effects of fluid resuscitation on, 51-53 Colloid-deferoxamine conjugates, 88 Colloid resuscitation, 47-51 complications of, 60-62 polydisperse, 62 studies of, 12 vs. crystalloid, 51 Colocalization, of inhibited protein synthesis, 37 Combat environment, 97-101 defined, 11 Combat trauma, no "golden hour" in, 9 Combatants expected condition of, 98 in future battles, 11 injury to, 113-114 limits of care on battlefield, 98-99 mortality rate in battle, 1, 9 resuscitation needs of, 99 tension pneumothorax in, 104-105 Compartmentalization, ion, 26-27 Compensatory mechanisms, 80 Complement activation, 84 "Congestive atelectasis," 15 Consent. See Informed consent Continuing medical education (CME), 122 Controlled hemorrhage, vs. uncontrolled, 112-113, 123 Cortisol, 112 Crocetin, 84 Crystalloid overresuscitation, 68 Crystalloid resuscitation, 15, 39, 47-51 aggressive, 67 complications of, 62-73 effects on immune function, 62-67 large volume, 15, 68-69 overall cautions concerning, 75 studies of, 12 for treating hypovolemia, 1 vs. colloid, 51 Cyclosporin, 85 Cytokine response, 29, 74, 85 effects of crystalloid resuscitation on, 67-68 effects of hypertonic saline-dextran on, 71 D "Danang lung," 15 "Death domain," 30 Decompensation, 24-25

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Deferoxamine (DFO) conjugates, 88 Delphi method, 61 Desferal, 88 DFO. See Deferoxamine conjugates Diagnostic instrumentation, for intervening in shock, 92 Diaspirin-cross-linked hemoglobin, 82 DIC. See Disseminated intravascular coagulation Dilutional thrombocytopenia, 40 Disseminated intravascular coagulation (DIC), 41-43 laboratory abnormalities in, 43 thrombosis accompanying, 42 D-lactate, 69-70 removing from lactated Ringer's solution, 3, 76 E Eastern Cooperative Oncology Group, 121 eIF2α, phosphorylated, 43 eIF4G caspase-mediated degradation of, 33 proteolytic degradation of, 33 Electrolyte characteristics, of selected resuscitation fluids, 49 Electron paramagnetic resonance (EPR) spectroscopy, 54 Endothelial cell function, resuscitation-related changes in, 53 Endothelin production, 52 Endotoxin shock, 28 Endpoints of clinical trials, 117-118 surrogate, 117 Energy depletion, 22 Energy metabolism, altered, 25-26 EPR. See Electron paramagnetic resonance spectroscopy Equipment, size and weight limits on, 99 Erythrocytes, 82 Estradiol, 92 Estrogenic effects, potential therapeutic effects of compounds with, 92 Evacuation limited on battlefield, 98 prompt aeromedical, 106 recommendation concerning, 106 Evaluating resuscitation protocols, 118-120 Exsanguination. See Blood loss Extraction reserve, 109 F FDA. See U.S. Food and Drug Administration First responders. See also "Trained responders" needs of, 2 new concept of, 11, 98-99 training, 102 treatment protocol for, 105 FK506, 85 Fluid overload, 68 Fluid redistribution, after major trauma, 48 Fluid resuscitation, 101 on battlefield, 99 defined, 11 experience with and complications of, 5, 47-76 history of, 12-15 immediate vs. delayed, 99 research on, 3 Fluids. See "Boutique fluids"; Resuscitation fluids; individual fluids Fractures, immobilizing, 99, 101 Free fatty acids, release during brain ischemia, 27 Free radical, damage by, 27-28 Free radicals confirming production of, 90 neutrophil-derived, 58 oxygen-derived, 55-56 preventing generation of, 85 reperfusion-mediated damage by, 54, 86-91 Free-radical scavengers, 53, 55 adding to lactated Ringer's solution, 3, 76 Future directions, in treating hemorrhagic shock, 6-7, 109-124

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G Gardenia jaminoides Ellis, 84 Gastrointestinal consequences of shock, 22 Genes. See Human genes Glasgow Coma Score, 118-119 Global ischemia, development of tolerance to, 4, 93 Glucocorticoids, 37 Glucose-containing solutions drawbacks off 60 as a resuscitation fluid, 60 Glutathione, 56 adding to lactated Ringer's solution, 3 "Golden hour," 9 Granulocyte colony-stimulating factor (GCSF), altering, 111 Growth factors, alterations in secretion of and cellular responsiveness to, 36-38 H Hematocrit decrease in, 52 restoring, 59 Hematologic abnormalities associated with shock, 38-43 disseminated intravascular coagulation, 42-43 transfusion-related, 39-42 Hematologic changes, 23 Hemoconcentration, 13 Hemodilution, 51-52 interoperative, 83 Hemodynamic measurements, 113 Hemoglobin. See also Stroma-free hemoglobin diaspirin-cross-linked, 82 polyoxyethlene, 82 recombinant, 82 Hemorrhage autoregulatory mechanisms involved in, 23-24 consequences triggered by, 4 controlled vs. uncontrolled, 112-113, 123 control of massive, 99 major cause of salvageable battlefield casualty, 10 physiologic responses to, 23-25 regulatory mechanisms involved in, 23 studies of effects of rates of, 110-111 studies of injury with, 111 treating on the battlefield, 103-105 Hemorrhagic gastritis, 22 Hemorrhagic shock animal models of, 109-112 associated with lactic acidosis, 28-29 definitions of, 19-23 future directions in treating. 6-7, 109-124 organ involvement in, 21-23 oxygen-derived free-radical-mediated injury in, 55-56 pathophysiology of acute, 19-44, 80 pure, 3 roles of induced nitric oxide in, 58 technical models of, 112-114 Hemostasis, achieving adequate, 29 Hemothorax, detection and treatment of, 99 Heparin therapy, 43 "Hibernation," pharmacologically induced, 93 Homeostasis, hypotheses involving. 110 Hormonal influences, intervening in shock, 92 HSD. See Hypertonic saline-dextran Human genes. encoding CED-9-related proteins, 32 Human immunodeficiency virus (HIV), transmitted through transfusion, 53 Human subjects, protection of, 120 Hydroxyethyl starch, 61 Hyperglycemia, in patients with shock, 38 Hypernatremia, 48 Hypertonic saline-dextran (HSD). 71-73 clinical trials of, 71-73 limits of, 72-73 Hypertonic saline solutions not causing neutrophil activation. 64 recommendation for using, 2, 103-104

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repeat administration of, 104 safety and efficacy of, 71-73 using minimum volumes of, 61 Hyponatremia, 48 Hypoperfusion, 25 Hypotension, studies of effects of, 110-111 Hypovolemia, crystalloid resuscitation for treating, 1 Hypovolemic shock after trauma, 47, 79 defined, 20-21, 80 Hypoxanthine, 55 Hypoxia, reducing vulnerability to, 4, 93 I Immune function effects of crystalloid resuscitation on, 62-67 effects of hypotension and hemorrhage on, 110-111 Immunochemical assays, 43 Immunological impairment, 22-23, 65-66 Indexing systems, of trauma research findings, 3, 123 Inducible isoform of nitric oxide synthase (iNOS), 89-90 Informed consent, 120 Injury. See also Combatants; Combat trauma inflammatory and organ dysfunction responses to, 50 penetrating vs. blunt, 15, 98, 113 protocols for care at the site of, 97-107 soft-tissue, 113 system for categorizing, 4 types of, 9-10 Injury severity score (ISS), 118-119 Inner city, casualties in, 15, 99 Institute of Medicine, 1, 16 Insulin high doses needed during postischemic reperfusion, 37 neuron-sparing effects of, 36-37 Insulin resistance, in patients with shock, 38 "Internal armor" concept, 92 Intervening in shock, 84-92 diagnostic instrumentation, 92 hormonal influences, 92 targets for, 84-86 therapies for reperfusion-mediated free-radical damage, 86-91 Intraosseous administration, 2, 103-104 Intravascular coagulation, disseminated, 42-43 Intravenous therapy, 101 Intubating laryngeal mask airway (LMA), 104 Ion compartmentalization, 26-27 Iron chelators, 88-89 adding to lactated Ringer's solution, 3 Ischemia. See also Brain ischemia; Global ischemia; Myocardial ischemia consequences triggered by, 4 enzymatic consequences of, 26-27 neuron-sparing effects in, 36 prolonged, 24 relationship to oxygen reperfusion, 87 transient forebrain, 37 "whole body," 55, 58 Ischemia-reperfusion research, 4, 82 Isobaric models, 109 Isotonic solutions, 39 large volume use of, 47 Israeli Defense Forces, 10 ISS. See Injury severity score K Ketones, adding to lactated Ringer's solution as an energy source, 3, 76 Korean War, 22, 39 Krebs cycle, failure of, 22 Kupffer cells, 28 L Lactated Ringer's solution adverse effects, 39, 67, 69-70 increasing neutrophil activation, 62 need for modifying, 2-3, 12-13, 76 safety of current regimens of, 70

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upregulation of intracellular adhesion molecules by, 58 Lactic acidosis, hemorrhagic shock associated with, 28-29 Large volume use of crystalloid resuscitation, 15, 68-69 of isotonic salt solutions, 47-48 Laryngeal mask airway (LMA), intubating, 104 "Lazarus solutions," 81 Lethal dose, 123 Leukocytosis, 84 Lipid metabolism, 27 Lipid peroxidation products and proteins, testing for, 43 Liposomes, for preventing shock, 83-84 L-lactate, reducing total load of in lactated Ringer's solution, 3, 76 LMA. See Laryngeal mask airway Longer-term survival, 3 Lysis of clots, 29 M Macrophage function, alterations in, 28-29 Major trauma, fluid redistribution following, 48 Massive transfusions, 40-41 defined, 40 Medical litter, monitoring, 106-107 Melatonin therapy, 91 Mercaptoethylguanidine (MEG), 85-86 Metabolic acidosis, 20, 39 Metabolic derangements, accompanying traumatic shock, 4 Metabolism of lipids, 27 of radicals, 27-28 Methionine, 32 Military Trauma Life Support course, 102 Mitochondrial aerobic metabolism, 26 Models of hemorrhagic shock. See Animal models; Technical models Monitoring cardiac output, 106-107 passive, 106 of vital signs, 106 Monitoring equipment, miniaturizing. 106-107 Monitoring medical litter, 106-107 Monoclonal antibodies. 89 Mortality rate of combatants in battle, 1, 9 reducing, 1-2 Myocardial contraction, decreased, 20 Myocardial ischemia, 30 N N-acetylcysteine, 86-87 NADPH. See Nicotinamide adenine dinucleotide phosphate National approach, needed in trauma research, 3-4 National Cancer Institute, 121 National Institutes of Health, 3, 124 National Research Council, 13, 15 Naval Blood Research Laboratory, 52 Naval operations, injuries in, 15 Needle thoracostomy, 100, 105 Nervous system. See Central nervous system Neurogenic shock, defined, 20-21 Neutrophils activated in reperfusion-mediated injury, 58-59, 62 fluorescence in, 62, 64 Nicotinamide adenine dinucleotide phosphate (NADPH) oxidase, 53 Nitric oxide (NO) mediating cell injury, 57 mediating platelet dysfunction, 52 in reperfusion-mediated injury, 56-58 Nitric oxide (NO) synthase inducible isoform of (iNOS), 89-90 phosphorylation of, 27 Nitrones, 90-91 Nitroxides, developing, 91 Nonlinear battlefields, 10 Nonthoracic trauma, 15 Normochloremic carbonate/carbon dioxide, 3 Novel approaches to treating shock, 4, 6, 75, 79-94 NOX, 90

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O Office of Naval Research, 1, 16 Oligosaccharides, 59 Oncotic proteins, 51 Operation Desert Storm, 106 Opsonic proteins, 51 Organelles. See Cellular organelles Overhydration, 15 Oxygen delivery consequences of impaired, 4 enhancing, 4 supraphysiologic concentrations of, 53-54 Oxygen-derived free radicals, in reperfusion-mediated injury, 55-56 Oxygen reperfusion, relationship to ischemia, 87 Oxygen therapeutics, for preventing shock, 80-82 Oxygen toxicity, associated with resuscitation, 53-54 Oxyglobin (veterinary use), 81 P Parameters, of fluid therapy fluids, 2 Parenteral saline, 3 normochloremic carbonate, 75 PARS. See Poly(ADP ribose) synthetase Pathophysiology of acute hemorrhagic shock, 19-44 Penetrating injury, 113-114 vs. blunt, 15, 98 Perfluorocarbons, as blood substitutes, 42 Perfluorochemicals, for preventing shock, 83 Peroxynitrite, 57-58 scavenging, 89 Pharmaceutical industry, 121 Phosphoprotein phosphatase1, 33 Phosphorylated eIF2α, testing for, 43 Phosphorylation auto-tyrosine, 36 tyrosine, 37 Physiologic responses to hemorrhage, 23-25 PKR. See Protein kinase Plasma. See Blood plasma; Reduced plasma Plasma catecholamines, 111 Plasmalemma receptor-activated caspase response, 31, 35 Platelet aggregation, 52 Platelet dysfunction, nitric oxide-mediated, 52 Pneumothorax, detection and treatment of, 99 Poly(ADP ribose) synthetase (PARS), 57 Polyhemoglobin, 86 Polymorphonuclear neutrophil adherence, inhibiting, 89 Polynitroxylation, of biomacromolecules, 82-83 Polyoxyethlene hemoglobin, 82 Polypharmaceutical treatment approaches, 44 Postischemic reperfusion, high doses of insulin needed during, 37 Prehospital Trauma Life Support (PHTLS) course, 102 Preventing shock, 80-84 first- to third-generation therapeutics, 82-83 liposomes, 83-84 oxygen therapeutics, 80-82 perfluorochemicals, 83 Private sector, 3 Professional organizations, 3 Prolactin release, 92 Protective equipment, need for research into, 92 Protein kinase (PKR), function of, 34 Protein synthesis colocalization of inhibited, 37 suppression of, 34 Proteolytic degradation, of eIF4G, 33 Protocols of care, 6, 97-107 current, 1, 100-101 evaluating efficacy of, 3 need to change, 2 Protocols of resuscitation, 118-120 Pulmonary edema, 69 contributing factors, 50 Pulmonary infection, following hemorrhagic shock, 28 Purines, oxidation by, 54 Pyruvate, pathway producing, 26

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R Radicals. See also Free radicals production and metabolism of, 27-28 Recombinant hemoglobin, 82 Recombinant technology, 61 Recommendations, 2-7 Red blood cell complement-mediated destruction of, 41 substitutes for, 40-41 Reduced plasma, 51 Renal failure, 21-22 Reperfusion neuron-sparing effects in, 36 postischemic, 37 Reperfusion-mediated injury, 54-59 activated neutrophils, 58-59 nitric oxide, 56-58 oxygen-derived free radicals, 55-56 therapies for intervening in, 86-91 treating, 4 Research, defined, 115-116 Respiratory failure. See Acute respiratory failure Responders. See First responders Resuscitation alternative approaches to, 73-74 complications of, 51-73 disadvantages to current solutions for, 2 evaluating protocols of, 118-120 hematologic abnormalities associated with, 38-43 immediate vs. delayed, 99 initial, 2 late, 59 oxygen toxicity associated with, 53-54 using colloids and crystalloids, 47-51 Resuscitation fluids developing new, 2 electrolyte characteristics of selected, 49 ideal, 79 for military use, 81 Resuscitation protocols, evaluating, 118-120 Revised Trauma Score (RTS), 118-119 Ringer's solution. See Lactated Ringer's solution Risks, of blood transfusion, 41 RTS. See Revised Trauma Score S Saline solutions. See also Hypertonic saline solutions controversy over, 47 Scavenging strategies, 86-87 Scoring systems, 118 Secondary shock, 13 Secretion of growth factors, alterations in, 36-38 Septic shock, 113 defined, 20-21 Shear stress, 52 Shock. See also Hemorrhagic shock; Secondary shock biochemical effects of, 22 cellular responses to, 4, 25-38 classifications of, 19-20 defined, 11, 19 future directions in treating, 6-7, 109-124 gastrointestinal consequences of, 22 hematologic abnormalities associated with, 38-43 increasing tolerance toward, 92-93 insulin resistance and hyperglycemia in patients with, 38 intervention, 4, 84-92 irreversibility in severe, 25 metabolic effects of, 22, 59 molecular responses to, 4 novel approaches to treating, 4, 6, 79-94 organ involvement in, 21 prevention, 80-84 Shock decompensation, 24-25 "Shock lung, 15, 39 Shock syndrome, treating complications of, 4 Signal transduction, 29 evolutionary development of mechanisms for, 35

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Site of injury, protocols for care at, 6, 97-107 SOD. See Superoxide dismutase Soft-tissue injury, 113 Southwest Oncology Group, 121 Special Operations forces, 98, 100 basic tactical casualty management plan for, 101 Spectrin, testing for calpain-specific degradation fragments of, 43 Starch-chelator conjugates, 88 Stress measurements, 113 Stroma-free hemoglobin, 42 Superoxide dismutase (SOD), 82, 86 Supplies and equipment, size and weight limits on, 99 Surgeon General's History of Surgery in World War II, 50 Surgical bleeding disorders, 29 Surrogate endpoints, 117 Survival, 115, 117-118, 123 longer-term, 3 probability of, 119 Systemic inflammatory responses, 62-64 T Tachycardia, 22 Technical models, of hemorrhagic shock, 112-114 Tension pneumothorax, 10, 100 in combat casualties, 104-105 detection and treatment of, 99 symptoms of, 105 Testosterone, adverse effects of, 92 Tetramers, 81 Therapeutic regimens, 97-107 current, 1, 100-101 "Third spacing," 48 Thoracostomy, 105 Thrombocytopenia, 51, 84 dilutional, 40 Thrombosis, accompanying disseminated intravascular coagulation (DIC), 42 Tirilazad mesylate, 88 Tissue macromolecules, radical-mediated damage to, 27 Tissue macrophages, activation of, 28 Tissue perfusion, decreased, 20, 25 T lymphocytes, 28 Torso, injuries to, 9 "Trained responders," 100 Training, for first responders, 102 Transcript formation, 34-35 Transcription and translation, fundamental alterations in, 29-36 Transfusions. See also Blood transfusions alternatives to, 41-42 massive, 40-41 of the patient in shock, 39-40 transmitting diseases, 41 Translation fundamental alterations in, 29-36 initiation system for protein synthesis, 32 Trauma among civilians, 98, 121, 123 among combatants, 9, 98-99 classifying severity of clinical, 3 fluid redistribution following major, 48 Trauma and injury severity score (TRISS) assessment methodology, 118-119 Trauma centers civilian, 121-122 clinical trials in, 3 regional, 3, 121-122 Trauma indexing, 3, 123 Trauma research, 3 national approach needed in, 3-4 Traumatic shock. See also Hemorrhagic shock associated with tissue injury, 3 defined, 20 metabolic and cellular derangements accompanying, 4 "Traumatic wet lung," 15 Treatment approaches, 102-107 airway and breathing, 104-106 future directions in, 6-7, 109-124 for hemorrhage, 103-104 monitoring, 106-107 novel, 4, 6, 79-94 prompt aeromedical evacuation, 106 repeat administration of hypertonic saline solution, 104

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TRISS. See Trauma and injury severity score Trolox, 87 Tubular necrosis, 39 Tumor necrosis factor a, 28, 30 21st century battlefields, 10, 97 Tyrosine phosphorylation, 37 U Uncontrolled hemorrhage, vs. controlled, 112-113, 123 U.S. Department of Defense, 3, 124 U.S. Department of Veterans Affairs, 3, 124 U.S. Food and Drug Administration (FDA), 116-117 U.S. Navy Seals, 103 Urban warfare, 97 Utstein system, 119 V Vasoactivity, factors influencing, 82 Vasoconstriction, 52 Vasopressin, release of, 24 Vietnam conflict, 10, 15, 22, 39, 50, 100 Viral diseases, transmitted by transfusions, 41, 53, 60 Vital signs, monitoring, 106 Vitamins, 87 adding to lactated Ringer's solution, 3 Volume replacement therapy, 4, 14 goal of early, 24-25 W Wars of the future, 10-11 World War I, 13-14, 39 World War II, 9, 15, 39, 50 Wounds data on. 10 dressing, 101 X Xanthine oxidase, 55 Y Yom Kippur War, 22

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