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PubMed1977

Pneumatic trousers and the management of shock.

Forty-seven patients were brought to the Emergency Department with a good blood pressure which probably would not have existed without the use of MAST Trousers. Most important, not one patient who survived the operation and immediate postoperative period developed adult respiratory distress syndrome or acute renal failure. It is our belief that prevention of prolonged hypotension in the prehospital period was a major factor in achieving this result.

Adolescent↗
PubMed1981

Limb loss following Military Anti-Schock Trousers (MAST) application.

External counterpressure is a safe and effective method to treat shock and restore central circulation. Experience with the short-term use of MAST has been favorable. If external counterpressure is maintained for extended periods, however, altered peripheral hemodynamics may result in permanent damage. The development of compartment syndrome requiring amputation is reported in two patients with associated leg fractures. This unfortunate experience suggests that the sustained use of MAST in patients with shock and comminuted lower extremity fractures may jeopardize limb survival.

Adult↗
PubMed1982

Compartment syndrome after anti-shock trouser use without lower-extremity trauma.

The use of anti-shock trousers is widely advocated for the treatment of hypovolemic shock. Despite its frequent use, few complications have been reported in the medical literature. Although speculation exists that anti-shock trouser application may result in ischemic injury to the lower extremities, this complication has only recently been reported. Our report describes a patient with no lower extremity trauma who developed bilateral anterior and lateral compartment syndromes after the application of anti-shock trousers.

Adolescent↗
PubMed1982

MAS trousers improperly applied causing a compartment syndrome in lower-extremity trauma.

A case is presented in which the leg segments of MAS trousers were deflated without deflating the abdominal segment, causing the trousers to act as a venous tourniquet. As a result bleeding and edema secondary to a pertrochanteric hip fracture were aggravated, causing a compartment syndrome in the thigh; fasciotomy became necessary. MAS trousers must be inflated in proper sequence, the leg segments first and then the abdominal portion. In deflation, the order is reversed. Only if this sequence is followed can MAS trousers be used safely.

Adult↗
PubMed1984

The prehospital use of external counterpressure: does MAST make a difference?

Military anti-shock trousers (MAST) have achieved widespread civilian usage because of reported effectiveness in treating hypovolemic shock. The literature, however, consists of either case reports or series in which no controls were evaluated. No published reports exist which compare similar groups of patients treated with and without MAST in the pre-hospital setting. We reviewed the paramedic and emergency department records of 226 patients sustaining moderate to severe trauma who were transported to San Francisco General Hospital by paramedics over a 15 month period. MAST usage during this period was approximately random as a result of logistical and training constraints. For analysis, patients were divided into two groups: those in whom MAST was applied and inflated during transport and those in whom it was not used. Paramedic interventions other than MAST were similar in both groups. Trauma Scores (TS), and blood pressure index (greater than 90 = 4, 70-89 = 3, 50-69 = 2, 0-49 = 1, no pulse = 0), were calculated for initial field observations and initial emergency room evaluation after hospital arrival. Patients with isolated head injury were excluded. The average change in TS and BP index (E.R.--field value) was calculated for MAST and non-MAST groups of patients. Mortality and total field times were also evaluated. Average TS and BP index increased slightly in both groups. Use of MAST produced no significant improvement in trauma score, BP index, or mortality over non-MAST patients. There was no demonstrable field benefit of MAST in fully arrested patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Blood Pressure↗
PubMed1984

Immediate hemodynamic consequences of MAST inflation in normo- and hypovolemic anesthetized swine.

Use of the military antishock trouser (MAST) remains controversial in part because its mechanism(s) of action are poorly understood. We studied two aspects of the hemodynamic response to MAST inflation in 14 anesthetized swine. First, in six swine the relation that existed between inferior vena cava flow and aortic pressure/cardiac output was determined before and during inflation of the MAST, and then before and after removal of 30% of the calculated blood volume. Inflation of the MAST before hemorrhage had little effect on cardiac output but increased aortic pressure by 25%. Inflation of the MAST after hemorrhage increased cardiac output by 41% and increased aortic pressure by 62%. Three different inflation pressures were studied (40, 80, and 120 mm Hg) and were found to give equivalent results. Inflation of the MAST translocated about 3 ml/kg of blood to the heart. A second group of eight swine were instrumented so that the radiomicrosphere technique could be used to measure organ blood flow. Inflation of the MAST following hemorrhage increased coronary perfusion by 50% and cerebral perfusion by about one third. Flow to kidney, liver, and small intestine was not changed. We conclude that, in addition to tamponade of venous bleeding and the splinting of lower extremity fractures, use of the MAST might cause a clinically important increase in the perfusion of the heart and brain in some trauma patients.

Anesthesia, General↗
PubMed1984

The effects of the pneumatic antishock garment on intracranial pressure in man: a prospective study of 12 patients with severe head injury.

Changes in intracranial pressure, mean arterial blood pressure, and cerebral perfusion pressure in response to sequential inflation of the pneumatic antishock garment were monitored in 12 patients with severe head injury and initial intracranial pressure less than 20 mm Hg. The small incremental increases in intracranial pressure that occurred with inflation of the pneumatic antishock garment were compensated for by improved hemodynamic stability and elevated mean arterial blood pressure which produced a simultaneous rise in cerebral perfusion pressure. The treatment of hypotension in traumatized patients with head injuries is paramount and sequential slow inflation of the pneumatic antishock garment can be used in such patients without apparent ill effect to the brain when the initial intracranial pressure is 20 mm Hg or below. Further study is needed to determine the safety of the device in head injured patients with elevated intracranial pressures.

Adolescent↗
PubMed1984

Venous return and the pneumatic antishock garment in hypovolemic baboons.

The pneumatic antishock garment is widely used in trauma patients because it compresses small veins and should augment venous return. If the garment does augment venous return, it should probably be used in all injured patients in shock, regardless of injuries and regardless of anticipated transport time. On the other hand, the garment could distort and narrow large retroperitoneal and abdominal veins and impede venous return. We quantitated venous return in normovolemic and hypovolemic baboons. The garment both augmented and impeded venous return, the two effects counteracting each other. We believe that the pneumatic antishock garment should be used selectively.

Angiography↗
PubMed1984

Crush syndrome with death following pneumatic antishock garment application.

PASG is commonly employed for the prehospital therapy of traumatic hypovolemic hypotension. Although complications are reportly uncommon, several reports of compartment syndromes after PASG application and the present report of a crush syndrome following PASG application raise serious questions about the currently accepted guidelines for PASG therapy.

Adult↗
PubMed1985

Prehospital advanced trauma life support for critical penetrating wounds to the thorax and abdomen.

The role of advanced trauma life support (ATLS) in the prehospital care of the critically injured is highly controversial. This study analyzes the efficacy of ATLS in the management of critical penetrating wounds of the thorax and abdomen. In the 2 1/2-year period ending July 1984, 203 consecutive patients underwent emergency laparotomy or thoracotomy for gunshot and stab wounds. All patients were treated in the field by advanced paramedics (EMT-P). For gunshot wounds the mean time (+/- S.E.M.) responding to the scene was 4.5 (+/- 0.29) minutes, on the scene 10.1 (+/- 0.41) minutes, and returning to the hospital 6.4 (+/- 0.32) minutes. For stab wounds the mean time responding to the scene was 4.8 (+/- 0.21) minutes, on the scene 9.5 (+/- 0.37) minutes, and returning to the hospital 5.7 (+ 0.30) minutes. The number of intravenous lines started averaged 1.8 per patient. Eighty-one patients had PASG applied and 28 patients underwent endotracheal intubation (21 orally, seven nasally). Thirty-three patients had no obtainable blood pressure, of whom six survived (18%). One hundred sixty (94%) of the remaining 170 patients who had any initial blood pressure survived. One hundred nine (55%) patients had an increase in BP greater than or equal to 10 mm Hg (average, 35.6 mm Hg), 64 (32%) had no significant change, and 25 (13%) had a fall greater than or equal to 10 mm Hg (average, 24.2 mm Hg) from the field to the emergency department. Twenty (80%) of the 25 patients with a fall in blood pressure survived.(ABSTRACT TRUNCATED AT 250 WORDS)

Abdominal Injuries↗
PubMed1985

Trendelenburg versus PASG application in moderate hemorrhagic hypoperfusion.

In hemorrhagic hypoperfusion one of the therapeutic goals of pneumatic antishock garment (PASG) application is to increase cardiac output, presumably by augmenting venous return from below the diaphragm, an effect expected to be similar to Trendelenburg positioning. The purpose of this study was to compare the hemodynamic response of these two common therapeutic interventions in hemorrhagic hypoperfusion. Five anesthetized dogs were bled over 10 minutes 24% of measured blood volume on two separate days. At the beginning of hemorrhage, they randomly received either PASG application or Trendelenburg positioning. PASG pressures of 30 +/- 5 mm Hg were applied to produce an inferior vena cava pressure of 10-15 mm Hg. Such PASG pressure had been shown previously to not diminish cardiac output from PASG application. Mean arterial pressure was maintained throughout the experiment with both therapies. With PASG application, cardiac index was depressed and systemic vascular resistance was elevated at 10, 20, and 30 minutes following hemorrhage. In contrast, Trendelenburg therapy maintained cardiac index and produced no significant increase in systemic vascular resistance index. Thus Trendelenburg therapy preserved mean arterial pressure primarily by maintaining cardiac output, probably by increasing venous return, whereas PASG application preserved mean arterial pressure primarily by increasing systemic vascular resistance. For treatment of moderate hemorrhagic hypoperfusion, Trendelenburg positioning may be superior therapy to PASG application.

Animals↗
PubMed1986

The effect of pneumatic antishock garments in the treatment of lethal combined hepatic and caval injuries in rats.

Thirty rats were subjected to a standardized lethal hepatic and retrohepatic caval vein injury. The animals were divided into six groups. In addition to controls (I), the animals were treated with a pneumatic antishock garment (PASG) (II), massive intravenous (III), or intra-aortic (IV), saline infusion, or PASG in combination with either massive intravenous (V) or intra-aortic (VI) saline infusion. Intravenous and intra-aortic infusion of saline led to a median survival time of 13 min and 37 min, respectively, not statistically different from the control group. Nine of ten animals who had the combined treatment with PASG and infusion of saline developed a fulminant pulmonary edema. The treatment with PASG alone, however, prolonged survival time significantly from a median survival time of 10 min in the control group, to greater than 120 min in the treated group.

Animals↗
PubMed1986

Prospective randomized evaluation of antishock MAST in post-traumatic hypotension.

During an 18-month period, among 35,000 injured patients presenting to an urban trauma center, more than 3,500 were admitted, and 1,500 underwent surgery on the General Surgical Service. Three hundred fifty-two patients with prehospital systolic blood pressures of less than 90 mm Hg were randomized on an alternate day basis to receive treatment with 'MAST' (163 patients) or 'No-MAST' (189 patients). Age, mechanism of injury, prehospital management times, prehospital trauma scores, prehospital fluids administered, Injury Severity Scores, emergency center treatment, operative protocol, and calculated probability of survival were virtually identical for both groups. Eighty-eight per cent of the injuries were produced by penetrating wounds. The predominant injury area was the abdomen in 40%, the thorax in 37%, and the extremities in 13%. There was no statistically significant difference in evaluation and outcome data between the groups. Within a controlled catchment, only 2.5% of injured patients and 22% of those undergoing operation qualified for prehospital use of MAST. We conclude that for penetrating trauma with prehospital times of 30 minutes or less, MAST provide no advantage with regard to survival, length of hospital stay, or reduced hospital costs.

Adult↗
PubMed1986

Hemorrhage associated with major pelvic fracture: a multispecialty challenge.

Definitive treatment of life-threatening hemorrhage associated with blunt pelvic fracture remains controversial. To elucidate this issue, we reviewed 538 consecutive patients admitted with acute pelvic fracture during a 5-year period. Injury mechanism was motor vehicular in 214 (40%), falls in 152 (28%), auto-pedestrian in 92 (17%), motorcycle in 46 (9%), crush in 26 (5%), and assault or skiing in eight (1%). Ninety-two (17%) of these patients required greater than 6 units of blood transfusion during the first postinjury day, and are the primary focus of this report. Twenty-five patients (28%) had unilateral anterior (Group I, n = 20) or posterior (Group II, n = 5) fractures. The remaining 67 patients (72%) had anterior and posterior element involvement on the same side (Group II, n = 38), bilaterally (Group IV, n = 14), or open perineal wounds (Group V, n = 15). The PASG was applied in 47 patients (51%), and controlled hemorrhage in 12 (71%) of the 17 in whom it was used alone to tamponade pelvic bleeding. Peritoneal lavage was performed in 73 patients (79%). Initial aspirate yielded gross blood in 32 patients; 27 (84%) of these required urgent laparotomy. External skeletal fixation was applied in 19 patients; bleeding was controlled in 18 (95%). Pelvic angiography identified active hemorrhage in three patients and selective embolization was successful in two. Sixty-eight (74%) of the high-risk patients survived. Thirteen (54%) of the 24 deaths were attributable to the pelvic trauma, ten were due to recalcitrant bleeding, and three to delayed sepsis.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1986

Pneumatic antishock garments (PASG): do they precipitate lower-extremity compartment syndromes?

Pneumatic antishock garments (PASG) are widely used for treatment of hypovolemic shock and for long-term control of bleeding associated with pelvic fractures. Several cases of compartment syndromes (CS) caused by PASG application, and with sequelae such as limb loss, myoglobinuric renal failure, and death have been reported. The aim of this study was to investigate the amount of PASG pressure needed to produce tissue anoxia. Twelve normotensive subjects were investigated, and transcutaneous oxygen tension (TcPO2) was measured beneath a full-length pneumatic splint at the following pressures applied: 0, 10, 15, 20, 25, 30, and 35 mm Hg. Without imposed pressure, mean TcPO2 was 70.6 mm Hg. TcPO2 decreased by increasing pneumatic pressure, expressed by the equation: TcPO2 = 2.3x + 65.7, where x is applied pressure in mm Hg. TcPO2 became zero at a mean applied pressure of 28 mm Hg (25-35). It is concluded that PASG pressures of 30 mm Hg or more applied to the whole limb stop microcirculation and result in tissue anoxia. Even low PASG pressures carry a high risk of precipitating CS. To avoid ischemic injury new guidelines for PASG application are discussed.

Adult↗
PubMed1987

Lower-extremity compartment syndromes associated with use of pneumatic antishock garments.

Pneumatic antishock garments (PASG) are frequently used to initially support and manage traumatic hypovolemic shock. PASG have been implicated in the development of complicating compartment syndromes of the lower extremities, but cause and effect have not been clearly defined. The present report documents the occurrence of bilateral compartment syndromes in uninjured lower extremities after using PASG and reviews similar reported cases.

Adult↗
PubMed1988

The effects of pneumatic antishock garments in the treatment of critical abdominal injuries in rats.

Thirty rats were subjected to a standardized critical aortic injury and divided into six groups. In addition to controls, the animals were treated with a pneumatic antishock garment (PASG), massive intravenous or intra-aortic saline infusion, or PASG in combination with either massive intravenous or intra-aortic saline infusion. Twenty-six rats were subjected to a standardized hepatic injury and divided into four groups. In addition to controls, the animals were treated with PASG, massive intravenous saline infusion, or PASG in combination with massive intravenous saline infusion. These animals were allowed to bleed for 5 minutes before the treatment was started. The treatment with PASG alone prolonged the median survival time significantly from 7 min in the control group to greater than 120 min in the PASG group in rats with an aortic injury and from 33 to greater than 120 min in rats with a hepatic injury. Intravenous infusion of saline did not prolong the median survival time. Intravenous infusion in combination with PASG did not have any positive effects on median survival time or median mean aortic pressure and failed to prolong the median survival time significantly in rats with a liver injury, as six out of eight animals developed a lethal pulmonary edema.

Abdominal Injuries↗
PubMed1989

Cerebral function monitoring in rats with a critical hepatic injury treated with pneumatic antishock garment and infusion.

Twenty-nine rats were subjected to a severe standardized hepatic injury and divided into four groups. In addition to controls, the animals were treated with PASG inflated to 40 mm Hg, PASG and infusion of Ringer's acetate, or PASG and infusion of Ringer's acetate and Dextran 70 in combination. The aim of the infusion therapy was to stabilize the mean aortic blood pressure at 60 mm Hg. PASG significantly prolonged the survival time and the time during which a sensory evoked response could be observed. The PASG also prolonged the time before the EEG amplitude began to decrease or a burst-suppression pattern appeared in the EEG. Intravenous infusion of Ringer's acetate did not prolong these times compared to when PASG was used alone; when Dextran 70 was added to the infusion therapy these times were reduced. Changes in the EEG were recorded at a mean aortic pressure of 60 mm Hg when infusions were given, whereas the aortic pressure had to fall to 40 mm Hg before any changes could be observed when no infusions were used.

Acute Disease↗