Resuscitation Of Trauma Patients Research Articles

Hypovolemic Shock Evaluated by Sonographic Measurement of the Inferior Vena Cava During Resuscitation in Trauma Patients

Inferior vena cava (IVC) diameter immediately after fluid resuscitation has not yet been investigated in trauma patients with shock on arrival. Between June 2004 and May 2005, 30 trauma patients with hemorrhagic shock were prospectively investigated. Using ultrasound, we measured maximum anterior-posterior diameter of the IVC just below the diaphragm in the hepatic segment, in the expiratory phase. This was performed on arrival and when systolic blood pressure had been raised to over 90 mm Hg by fluid resuscitation in the emergency room. Subjects were divided into two groups: a transient responder group (n = 17) in which shock recurred after leaving the emergency room and a responder group (n = 13) in which blood pressure remained stable. There were no significant differences between the two groups regarding age or gender, or regarding vital signs or IVC diameter on arrival. Average injury severity score in the transient responder group was significantly greater than that in the responder group. After fluid resuscitation, no significant intergroup differences were observed regarding vital signs. However, IVC diameter was significantly smaller in the transient responder group than in the responder group (6.5 +/- 0.5 mm; mean +/- SE vs. 10.7 +/- 0.7 mm, p < 0.05). In trauma patients, inadequate dilatation of the IVC by fluid resuscitation, might indicate insufficient circulating blood volume despite normalization of blood pressure. In this small study, IVC diameter appeared a better predictor of recurrence of shock than blood pressure, heart rate, or arterial base excess. A larger prospective study is called for to clearly establish the sensitivity and specificity of this method.

Use of the Lateral Circumflex Femoral Artery Perforator Flap in the Reconstruction of Gunshot Wounds to the Face

The reconstruction of large avulsive tissue loss in the head and neck region is one of the most difficult tasks faced by reconstructive surgeons. The advent of free tissue transfer has improved our ability to predictably reconstruct these patients. One of the most recent advances in the field of microvascular surgery is the use of perforator flaps. We have used the lateral circumflex femoral artery perforator (LCFAP) flap for reconstructions in patients who have suffered severe gunshot wounds (GSWs) to the maxillofacial area. A retrospective chart review was conducted of patients treated with a LCFAP flap in our division for large defects of the face resulting from GSWs between July 2005 and July 2006. The patient's age and gender, site and size of defect, and degree of bone and soft tissue loss were recorded. Flap survival and donor site morbidity were noted as outcomes of the reconstruction. Four patients who met the inclusion criteria were identified. The success rate for the flaps was 100%. There was no partial necrosis of the flaps. The size of the defect ranged from 20 x 10 cm to 10 x 10 cm. None of the patients had donor site complications, and all donor sites were closed primarily. Use of the LCFAP flap for the reconstruction of large defects secondary to GSWs to the face is a reliable option for the immediate reconstruction of this patient population. The lateral circumflex femoral artery perforator (LCFAP) flap is at a site not involved in the immediate resuscitation of trauma patients, thus ensuring an intact vascular system. This fact makes the LCFAP flap a reliable source for small to large soft tissues for reconstructing avulsive soft tissue losses in the head and neck.

EFFECT OF BRAIN COOLING ON BRAIN ISCHEMIA AND DAMAGE MARKERS AFTER FLUID PERCUSSION BRAIN INJURY IN RATS

Although systemic cooling had recently been reported as effective in improving the neurological outcome after traumatic brain injury, several problems are associated with whole-body cooling. The present study was conducted to test the effectiveness of brain cooling without interference with the core temperature in rats after fluid percussion traumatic brain injury (TBI). Brain dialysates ischemia (e.g., glutamate and lactate-to-pyruvate ratio) and injury (e.g., glycerol) markers before and after TBI were measured in rats with mild brain cooling (33 degrees C) and in the sham control group. Brain cooling was accomplished by infusion of 5 mL cold saline via the external jugular vein under general anesthesia. The weight loss was determined by the difference between the first and third day of body weight after TBI. The maximum grip angle in an inclined plane was measured to determine motor performance, whereas the percentage of maximal possible effect was used to measure blockade of proprioception. The triphenyltetrazolium chloride staining procedures were used for cerebral infarction assay. As compared with those of the sham-operated controls, the animals with TBI had higher values of extracellular levels of glutamate, lactate-to-pyruvate ratio, and glycerol in brain and intracranial pressure, but lower values of cerebral perfusion pressure. Brain cooling adopted immediately after TBI significantly attenuated the TBI-induced increased cerebral ischemia and injury markers, intracranial hypertension, and cerebral hypoperfusion. In addition, the TBI-induced cerebral infarction, motor and proprioception deficits, and body weight loss evaluated 3 days after TBI were significantly attenuated by brain cooling. We successfully demonstrate that brain cooling causes attenuation of TBI in rats by reducing cerebral ischemia and injury resulting from intracranial hypertension and cerebral hypoperfusion. Because jugular venipuncture is an easy procedure frequently used in the emergency department, for preservation of brain function, jugular infusion of cold saline may be useful in resuscitation for trauma patients.

Hydroxyethyl Starch for Resuscitation of Trauma Patients

Hydroxyethyl Starch for Resuscitation of Trauma Patients

202: Near-Infrared Spectroscopy During Resuscitation of Trauma Patients Predicts Future Development of Multiple Organ Dysfunction

Near-infrared spectroscopy (NIRS) non-invasively monitors muscle tissue oxygen saturation (StO2). It may provide a continuous noninvasive measurement to identify occult hypoperfusion, guide resuscitation, and predict the development of Multiple Organ Dysfunction (MOD) after severe trauma. Lactate and Shock Index (SI) have also been identified as markers that predict outcome and assist in trauma resuscitation. Our purpose was to evaluate the correlation between StO2 and these known markers patients as well as assess the correlation between initial StO2 and the development of MOD in multi-trauma patients.

Predictors of Fluid Resuscitation in Pediatric Trauma Patients

Predictors of Fluid Resuscitation in Pediatric Trauma Patients

Near-infrared spectroscopy during resuscitation of trauma patients predicts development of multiple organ dysfunction: a prospective cohort study

Near-infrared spectroscopy (NIRS) noninvasively monitors muscle tissue oxygen saturation (StO2). It may provide a continuous measurement to identify occult hypoperfusion, guide resuscitation, and predict the development of multiple organ dysfunction (MOD) after severe trauma. We evaluated the correlation between initial StO2 and the development of MOD in multitrauma patients.

Systemic hypotension is a late marker of shock after trauma: a validation study of Advanced Trauma Life Support principles in a large national sample

Background Systolic blood pressure is used extensively to triage trauma patients as stable or unstable, contrary to Advanced Trauma Life Support recommendations. We hypothesized that systemic hypotension is a late marker of shock. Methods The National Trauma Data Bank was queried (n = 115,830). Base deficit was used as a measure of circulatory shock. Systolic blood pressure was correlated with the presence and the severity of base-deficit derangement. Results Systolic blood pressure correlated poorly with base deficit (r = .28). There was wide variation in systolic blood pressure within each base-deficit group. The mean and median systolic blood pressure did not decrease to less than 90 mm Hg until the base deficit was worse than −20, with mortality reaching 65%. Conclusions We validated the Advanced Trauma Life Support principle that systemic hypotension is a late marker of shock. A normal blood pressure should not deter aggressive evaluation and resuscitation of trauma patients.

Predictors of fluid resuscitation in pediatric trauma patients

Advanced Trauma Life Support (ATLS) is accepted as the standard for the first hours of trauma care. However, ATLS is designed primarily for adults. In children, vascular access can be difficult and time-consuming. Due to the differences in the epidemiology of children suffering traumatic injury, they may not require aggressive fluid resuscitation. The objective of the study was to establish predictors of fluid resuscitation, and to determine whether all pediatric Level I Trauma victims require two intravenous catheters. Medical charts of all patients aged < 18 years meeting Level I Trauma criteria who presented to Childrens Hospital Los Angeles (CHLA) between January 1 and December 31, 1999 were retrospectively reviewed. There were 152 patients reviewed with a median age of 6 years (range 4 months to 17 years); 64% were boys. The mechanism of injury was motor vehicle crash 49%, fall 37%, crush 8%, gunshot 5%, and knife 1%. Injuries included closed head 88%, penetrating abdomen/chest 6%, and other 6%. Vital signs over time showed no change in 59%, got better in 34%, and got worse in 7%. Fluid resuscitation included no bolus in 70%, 1 bolus in 20%, 2 boluses in 7%, > 2 boluses in 3%. The ICU admitted 23%, 12% were intubated, survival was 95%, and 59% received a prehospital i.v. The i.v. #1 site: antecubital 51%, hand 41%, foot 5%, femoral 1%. The i.v. #2 site: hand 30%, antecubital 20%, foot 2%, none 48%. T test showed no statistically significant differences in fluid resuscitation or second i.v. placement based on the mechanism of injury. T test for unequal variances showed a statistically significant difference in means with p < 0.001 for second i.v. placement as compared with only i.v. fluid amount, age, and Injury Severity Score (ISS). Revised Trauma Score was the only predictor of worsening of vital signs (logistic regression [LR], p < 0.001). Age was the only predictor of second i.v. placement (LR, p < 0.03). ISS was the only predictor of a bolus being given (LR, p < 0.01). In our study, blunt trauma occurred in 90% of children, with 10% requiring > 1 fluid bolus. ISS was the only predictor of the need for fluid resuscitation and is not likely to be helpful in the clinical setting. In our population, nearly 50% had no second i.v. This preliminary review of the nature of pediatric trauma suggests that ATLS guidelines may not always be appropriate for the management of pediatric trauma.

Personal view: crystalloid transfusion in acute gastrointestinal haemorrhage: is it beneficial? An historical perspective

The conventional management of acute gastrointestinal haemorrhage mandates early repletion of blood volume with crystalloids and blood, as part of the initial management, where there is evidence of hypovolaemia. Meanwhile there is a major trend towards a restrained use of fluid to raise blood pressure to near normal for the bleeding patient in trauma and similar emergencies. This divergence of view requires analysis. An Ovid/MEDLINE, Google and extensive literature search focused on the resuscitation and transfusion of bleeding trauma patients was performed. In addition to clear evidence from animal experiments that early restoration of blood volume perpetuates bleeding, there is considerable evidence in humans - both in war and civilian life - that rapid crystalloid infusion is harmful. I also report a personal series of benefit from restricted transfusion in acute upper gastrointestinal haemorrhage in humans. Given the lack of evidence of benefit for rapid blood volume repletion in acute gastrointestinal haemorrhage, there is need for controlled studies of the most appropriate approach to crystalloid transfusion in acute gastrointestinal bleeding.

The Use of Fresh Whole Blood in Massive Transfusion

Most indications for whole blood transfusion are now well managed exclusively with blood component therapy, yet the use of fresh whole blood for resuscitating combat casualties has persisted in the U.S. military. Published descriptions of whole blood use in military and civilian settings were compared with use of whole blood at the 31st Combat Support Hospital (31st CSH) stationed in Baghdad in 2004-2005. Concerns about logistics, safety, and relative efficacy of whole blood versus component therapy have argued against the use of whole blood in most settings. However, military physicians have observed some distinct advantages in fresh warm whole blood over component therapy during the massive resuscitation of acidotic, hypothermic, and coagulopathic trauma patients. In this critical role, fresh whole blood was eventually incorporated as an adjunct into a novel whole-blood-based massive transfusion protocol. Under extreme and austere circumstances, the risk:benefit ratio of whole blood transfusion favors its use. Fresh whole blood may, at times, be advantageous even when conventional component therapy is available.

Normotensive and hypotensive closed-loop resuscitation using 3.0% NaCl to treat multiple hemorrhages in sheep*

NaCl solutions (7.5%) have been reported to be effective for resuscitation in animals and trauma patients, but these solutions are not approved for use in the United States. We hypothesized that infusion of Food and Drug Administration-approved 3% NaCl provides superior cardiovascular and metabolic function while reducing the overall fluid requirement for resuscitation of hemorrhage. Our objective was to compare four groups, hypotensive and normotensive resuscitation of hemorrhage using 3% NaCl (HS) or lactated Ringer's (LR). Sheep were hemorrhaged in three separate bleeds, 25 mL/kg at T0 mins and 5 mL/kg at both T50 and T70 mins. University laboratory. Instrumented conscious sheep. Resuscitation was started at T30 mins and continued until T180. Normotensive and hypotensive resuscitation to mean arterial pressures of 90 mm Hg and 65 mm Hg, respectively, was performed with LR or HS using a closed-loop resuscitation system. All four groups were successfully resuscitated to near target levels. Two animals in the hypotensive treatment protocols died during the second and third bleeding, one with the LR65 group and one with the HS65 group. Mean infused volumes were 59.9 +/- 7.0 and 18.0 +/- 5.9 in the LR90 and LR65 groups, respectively, and were 19.6 +/- 2.2 mL/kg and 13.3 +/- 5.7 mL/kg in the HS90 and HS65 treatments (p < .05; LR90 vs. each of the groups). Cardiac indexes were significantly higher with normotensive vs. hypotensive treatment. However, there was no hemodynamic advantage apparent with HS vs. LR when compared with the normotensive or hypotensive treatments. Some animals had high lactate levels (>10 mmol) with both of the hypotensive treatments and also with the HS90 treatment, while not one of the 11 LR90 treatment animals had lactate levels >8 mmol. Volume sparing was apparent with HS, but no hemodynamic or metabolic advantage was apparent when used for either normotensive or hypotensive resuscitation. Trends toward lower base excess values and higher occurrences of deaths only in the hypotensive treatment protocols suggest that resuscitation to a target mean arterial pressure of 65 mm Hg may be too low.

What a belly ache

You are a medical student attached to a general surgery firm. While you are shadowing the senior house officer he is contacted for a trauma case; you accompany him to the resuscitation bay of the emergency department. The trauma team awaits the arrival of a patient with an abdominal stab wound. You stand clear and observe the ordered and calm way in which the patient is dealt with on arrival. After a short period of initial assessment and resuscitation, consent is given for surgery and the patient is transferred to the acute theatre, where he is anaesthetised and prepared for an operation (fig 1). Fig 1 Patient prepared for laparotomy 1. What is the ordered approach for the assessment and resuscitation of trauma patients? 2. Why was this patient taken to theatre withoutpreoperative imaging? 3. The patient's head is towards the top left of the picture under the drape. The umbilicus is pooled with betadine preparation solution. Describe the location of the injury and list the organs and structures the surgeons are most worried about? 1. The advanced trauma life support method.1 2. The knife required removal under surgical control and the patient was haemodynamically stable and adequately …

The Immunomodulatory Effects of Hypertonic Saline Resuscitation in Patients Sustaining Traumatic Hemorrhagic Shock

To investigate the potential immunologic and anti-inflammatory effects of hypertonic saline plus dextran (HSD) in hemorrhagic trauma patients. Unbalanced inflammation triggered by shock has been linked to multiorgan dysfunction (MOD) and death. In animal and cellular models, HSD alters the inflammatory response to shock, attenuating MOD and improving outcome. It remains untested whether HSD has similar effects in humans. A single 250-mL dose of either HSD (7.5% NaCl, 6% dextran-70) or placebo (0.9% NaCl) was administered to adult blunt trauma patients in hemorrhagic shock. The primary outcome was to measure changes in immune/inflammatory markers, including neutrophil activation, monocyte subset redistribution, cytokine production, and neuroendocrine changes. Patient demographics, fluid requirements, organ dysfunction, infection, and death were recorded. A total of 27 patients were enrolled (13 HSD) with no significant differences in clinical measurements. Hyperosmolarity was modest and transient, whereas the immunologic/anti-inflammatory effects persisted for 24 hours. HSD blunted neutrophil activation by abolishing shock-induced CD11b up-regulation and causing CD62L shedding. HSD altered the shock-induced monocyte redistribution pattern by reducing the drop in "classic" CD14 and the expansion of the "pro-inflammatory" CD14CD16 subsets. In parallel, HSD significantly reduced pro-inflammatory tumor necrosis factor (TNF)-alpha production while increasing anti-inflammatory IL-1ra and IL-10. HSD prevented shock-induced norepinephrine surge with no effect on adrenal steroids. This first human trial evaluating the immunologic/anti-inflammatory effects of hypertonic resuscitation in trauma patients demonstrates that HSD promotes a more balanced inflammatory response to hemorrhagic shock, raising the possibility that similar to experimental models, HSD might also attenuate post-trauma MOD.

Elevated Orbital Pressure: Another Untoward Effect of Massive Resuscitation after Burn Injury

Fluid resuscitation remains a fundamental component of early burn care management. However, recent studies suggest that excessive volumes of resuscitation are being administered. Overresuscitation results in negative sequelae including abdominal and extremity compartment syndromes. Elevated intraocular pressure (IOP) has been described as another potentially devastating effect of massive fluid resuscitation in trauma patients. The orbit, similar to the abdomen and extremity, is a compartment, limited to expansion from edema anteriorly by the eyelids and orbital septum, and posteriorly by the bony orbital walls. The purpose of this study was to review the incidence of elevated IOP in a series of patients with major burn injury. We retrospectively reviewed the charts of 13 consecutive patients admitted to our burn center with burn sizes >25% total body surface area (TBSA). All patients underwent serial IOP measurements for the first 72 hours following admission. Medical records were reviewed for fluid resuscitation volume, IOP measurements, need for canthotomy, and results of canthotomy procedures. Five of 13 patients had IOP >30 mm Hg and required lateral canthotomy. Canthotomy immediately reduced IOP (p = 0.009). Patients who developed elevated IOP received a significantly larger fluid resuscitation (9.0 cc/kg/%TBSA versus 6.0 cc/kg/%TBSA, p = 0.02). Elevated IOP was significantly associated with delivery of larger fluid resuscitation volume (p = 0.027). Massive fluid resuscitation following burn injury can result in orbital compartment syndrome requiring lateral canthotomy. Early diagnosis and treatment of orbital compartment syndrome should be incorporated into the management of patients with major burn injury receiving large fluid resuscitation volume.

Fluid resuscitation in trauma

Appropriate fluid replacement is an essential component of trauma fluid resuscitation. Once hemorrhage is controlled, restoration of normovolemia is a priority. In the presence of uncontrolled haemorrhage, aggressive fluid management may be harmful. The crystalloid-colloid debate continues but existing clinical practice is more likely to reflect local biases rather than evidence based medicine. Colloids vary substantially in their pharmacology and pharmacokinetics,and the experimental finding based on one colloid cannot be extrapolated reliably to another. In the initial stages of trauma resuscitation the precise fluid used is probably not important as long as an appropriate volume is given. Later, when the microcirculation is 'leaky', there may be some advantages to high or medium weight colloids such as hydroxyethyl starch. Hypertonic saline solutions may have some benefit in patients with head injuries. A number of hemoglobin solutions are under development, but one of the most promising of these has been withdrawn recently. It is highly likely that at least one of these solutions will eventually become routine therapy for trauma patient resuscitation. In the meantime, contrary to traditional teaching, recent data suggest that restrictive strategy of red cell transfusion may improve outcome in some critically ill patients.

Fluid resuscitation of trauma patients: how fast is the optimal rate?

The Advanced Trauma Life Support guidelines recommend an initial rapid infusion of fluid (1-2 L) in trauma and hemorrhage victims as a diagnostic procedure to aid treatment decisions. Although patient response to initial fluid resuscitation is the key to determining therapeutic strategies, the appropriate rate of infusion is not clearly defined. Ninety-nine adult (age >16 years) blunt trauma victims with hypotension were enrolled. Patients were classified into 3 groups according to hemodynamic state after initial fluid resuscitation and requirement of surgical intervention. Total volume and rate of infusion differed significantly between the groups ( P < .05). Patients requiring fluid administration at higher rate were all hemodynamically unstable and required immediate surgical intervention. Moreover, rate of infusion was the best predictor of the patients who required immediate surgical intervention. Moderate fluid infusion rate should be considered to allow identification of the patient's response to initial fluid resuscitation.

Prehospital Management and Fluid Resuscitation in Hypotensive Trauma Patients Admitted to Karolinska University Hospital in Stockholm

Few previous studies have been conducted on the prehospital management of hypotensive trauma patients in Stockholm County. The aim of this study was to describe the prehospital management of hypotensive trauma patients admitted to the largest trauma center in Sweden, and to assess whether prehospital trauma life support (PHTLS) guidelines have been implemented regarding prehospital time intervals and fluid therapy. In addition, the effects of the age, type of injury, injury severity, prehospital time interval, blood pressure, and fluid therapy on outcome were investigated. This is a retrospective, descriptive study on consecutive, hypotensive trauma patients (systolic blood pressure < or = 90 mmHg on the scene of injury) admitted to Karolinska University Hospital in Stockholm, Sweden, during 2001-2003. The reported values are medians with interquartile ranges. Basic demographics, prehospital time intervals and interventions, injury severity scores (ISS), type and volumes of prehospital fluid resuscitation, and 30-day mortality were abstracted. The effects of the patient's age, gender, prehospital time interval, type of injury, injury severity, on-scene and emergency department blood pressure, and resuscitation fluid volumes on mortality were analyzed using the exact logistic regression model. In 102 (71 male) adult patients (age > or = 15 years) recruited, the median age was 35.5 years (range: 27-55 years) and 77 patients (75%) had suffered blunt injury. The predominant trauma mechanisms were falls between levels (24%) and motor vehicle crashes (22%) with an ISS of 28.5 (range: 16-50). The on-scene time interval was 19 minutes (range: 12-24 minutes). Fluid therapy was initiated at the scene of injury in the majority of patients (73%) regardless of the type of injury (77 blunt [75%] / 25 penetrating [25%]) or injury severity (ISS: 0-20; 21-40; 41-75). Age (odds ratio (OR) = 1.04), male gender (OR = 3.2), ISS 21-40 (OR = 13.6), and ISS >40 (OR = 43.6) were the significant factors affecting outcome in the exact logistic regression analysis. The time interval at the scene of injury exceeded PHTLS guidelines. The vast majority of the hypotensive trauma patients were fluid-resuscitated on-scene regardless of the type, mechanism, or severity of injury. A predefined fluid resuscitation regimen is not employed in hypotensive trauma victims with different types of injuries. The outcome was worsened by male gender, progressive age, and ISS > 20 in the exact multiple regression analysis.

INJURY-ASSOCIATED HYPOTHERMIA: AN ANALYSIS OF THE 2004 NATIONAL TRAUMA DATA BANK

Severe injury and shock are frequently associated with abnormalities in patient body temperature. Substantial increases in mortality have been associated with profound hypothermia, especially below 35 degrees C. The purpose of this study was to further characterize the impact of hypothermia in a large dataset of trauma patients. This study was a retrospective analysis of the 2004 version of the National Trauma Data Bank (NTDB), which contains approximately 1.1 million patients from over 400 trauma centers. Admission temperature was analyzed with respect to mortality, injury severity score (ISS), base deficit (BD), Glasgow Coma Score (GCS), and hospital outcomes. The NTDB contained 701,491 patients with temperatures recorded upon trauma center admission. Of these, 11,026 patients had admission temperatures <35 degrees C, and 802 had temperatures <32 degrees C. Comparison of core temperature versus mortality revealed that as temperature decreased, the mortality rate increased, reaching approximately 39% at 32 degrees C, and remained constant at lower temperatures. Surprisingly, 477 patients (59.5%) survived with temperatures <32 degrees C. Similarly, BD increased as hypothermia worsened until body temperature reached 31 degrees C, below which there was little further increase. Patients with admission temperatures less than 35 degrees C had significantly greater mortality (25.5% vs. 3.0%, P < 0.001) and BD (7.8 vs. 3.7, P < 0.001) when compared with patients with temperatures >or=35 degrees C. In survivors, average ventilator days and intensive care unit (ICU) days were 14.4 and 12.8, respectively, for patients with temperatures <35 degrees C as opposed to more normothermic patients who demonstrated an average of 9.5 ventilator days and 9.1 ICU days (P < 0.001). When grouped by individual ISS, BD level, and GCS motor score, mortality was significantly greater when admission temperature was below 35 degrees C (ISS mean difference = 11.4%, BD mean difference = 22.8%, and GCS motor mean difference = 9.85%). Logistic regression revealed that hypothermia remains an independent determinant of mortality after correction for confounding variables (odds ratio = 1.54, 95% confidence interval 1.40-1.71). Admission hypothermia is associated with greater mortality, increased injury severity, more profound acidosis, and prolonged ICU/ventilator courses. However, although mortality at <32 degrees C is high, patients with temperatures this low do survive. As temperatures drop below 32 degrees C, mortality rates remain constant, which may indicate a threshold below which physiologic mechanisms are unable to correct body temperature regardless of injury severity. Although shock severity is highly indicative of outcome, hypothermia independently contributes to the substantial mortality associated with severe injury.

The Role of Transesophageal Echocardiography in Optimizing Resuscitation in Acutely Injured Patients

The goal of resuscitation is to correct the mismatch between oxygen delivery and that of cellular demands. The pulmonary artery catheter (PAC) is frequently used to gauge the adequacy of resuscitation and guide therapy based on ventricular filling pressures. Transesophageal echocardiography (TEE) has emerged as a potential tool in assessing adequacy of acute hemodynamic resuscitation. The purpose of this study was to evaluate the role of TEE in assessing preload during ongoing volume resuscitation in trauma patients. A retrospective review was conducted of acutely injured patients undergoing TEE during resuscitation from hemorrhagic shock from January 2002 to 2004 at a Level I trauma center. The indication for TEE was persistent hemodynamic instability in the absence of ongoing surgical hemorrhage. Variables included hemodynamic and PAC parameters, pre-TEE resuscitation volume, and vasopressor requirements. The impact of TEE findings on therapeutic decisions was evaluated. Twenty-five patients underwent TEE, 18 (72%) had an indwelling PAC with a mean pulmonary artery occlusion pressure of 19.3 mm Hg (range, 12-29 mm Hg) and mean cardiac index of 2.9 L/min/m2 (range, 1.6-4.6 L/min/m2). Twelve patients (48%) were receiving inotropes and/or vasopressors for hypotension at the time of TEE. Resuscitation volume within 6 hours before TEE included a mean of 6.5 L of crystalloid and 12.2 units of blood products (packed red blood cells, fresh frozen plasma, and platelets). TEE revealed left ventricular hypovolemia in 13 patients (52%) and altered therapy in 16 patients (64%), including additional volume (n = 13), addition of an inotrope (n = 4), and addition of a vasodilator (n = 1) in one patient with ventricular overdistention. Comparison of the abnormal and normal TEE groups revealed that only cardiac index was significantly different (2.6 L/min/m2 in the abnormal group vs. 3.9 L/min/m2 in the normal group; p = 0.005). Significant mitral valve regurgitation leading to valve replacement was identified in one patient. No clinically relevant pericardial effusion was identified. TEE altered resuscitation management in almost two thirds of patients. Many patients with "acceptable" pulmonary artery occlusion pressure parameters may in fact have inadequate left ventricular filling. In addition, TEE offers the advantage of direct assessment of cardiac valve competency, myocardial wall contractility, and pericardial fluid.