Trauma care has improved considerably over the past 25 years, largely from combined improvements in assessment, triage, resuscitation, and emergency and intensive care. The development of trauma centers has continued to evolve in North America with data supporting their efficacy. However, a study in patients with penetrating torso injuries rapidly transferred to a level 1 trauma center has shown that IV fluid resuscitation should be limited in the absence of significant head trauma, as massive fluid administration early after hemorrhage may increase bleeding by raising in-travascular pressures, disrupting clot formation, and diluting coagulation factors.
Monitoring the brain remains difficult, although intracranial pressure monitoring is now widely used. Tissue oxygen monitoring or microdialysis techniques have become available, but how they contribute to decreased complications is hard to define. We still lack good markers of cerebral damage, so that the evaluation of cerebral lesions remains largely based on the Glasgow coma score and neurologic status. Evaluation of cerebral blood flow and oxygen availability at the bedside remains difficult. other
Induced hypothermia can protect the neurons in hypoxic encephalopathy, but the beneficial effects in traumatic states have not been established. Thrombolytic therapy with tissue plasminogen activator improves outcomes when given early (within 3hof onset) to patients with ischemic stroke. Hyperglycemia may aggravate cerebral lesions, another reason to closely monitor blood sugar levels (see below).
Stricter control of blood sugar levels has been shown to decrease mortality in a mixed group of ICU patients, primarily surgical, many being admitted after cardiac surgery. Trials are underway to try to better target the most beneficial glucose level in medical-surgical ICU patients. The administration of steroids in septic shock has evolved over time, with the use of massive doses of methylprednisolone to limit the inflammatory response being replaced by the concept of relative adrenal insufficiency, leading to the administration of low doses of hydrocortisone in septic shock. Vasopressin administration in septic shock may also be based on relative deficiency in these circumstances. Trials are underway to define the potential benefit of administration of low doses of vasopressin in septic shock.