16C. Gaarder et al. the prehospital careprovider with amoreorless obvious mechanismo fi njury,c omplaintsa nd symptoms, and with many uncontrolled factors making both diagnosis and triage achallenge.Vo lume loading results in adecrease in haemoglobin and clotting factors. Furthermore, the relative expansion with 500 ml of isotonic crystalloid is greater in as hocked person than in ah ealthy individual. The optimal volume of intravenous fluid to administer is abalance between avoiding hypovolaemia and not increasing systolic blood pressure(SBP) causing disruption of clots and further bleeding. To what extent this is moret han at heoretical worry in patients with blunt trauma, is not well documented. Several animal models of penetrating injury,h owever,h ave documented the relationship between increasing blood pressure, increased bleeding and fatal outcome.AS BP <90m mH gi su sed extensively to assess volume status in trauma patients, both for triage, treatment and study protocols. How well aSBP <90 mm Hg defines the presence of uncontrolled bleeding, the need for intravenous fluid resuscitation and later surgical interventions is still not clear.T herei s also some evidence to support the use of only manual SBP for pre-hospital, or hospital, triage decisions (1).In EMS (Emergency Medical Services) systems wherep re-hospital fluid therapy is used, the incidence of hypotension at hospital admission is lower than 10% and the need for immediate haemostatic surgery is low (5). Recent publications have reinforced the impression that fluid resuscitation and blood transfusion in the Emergency Department still aree ssential elements of early management in most critically injured patients. Hence, providing the same therapy earlier,i fn ot exaggerated, seems logical. A major concern with prehospital fluid therapy is that infusing cold fluids will cause hypothermia in the patients, afactor known to reduce clotting activity.Patients with severeT BI (traumatic brain injury) do not tolerate even short periods of hypotension. Hence, theu se of volume therapy to counteract hypovolaemia and hypotension is considered standard treatment by most authors. The discussion has been focused moreonwhat systolic blood pressuretoaim for and what fluid to use. RECOMMENDATIONS

BackgroundEarly intramedullary nailing (IMN) of long bone fractures in severely injured patients has been evaluated as beneficial, but has also been associated with increased inflammation, multi organ failure (MOF) and morbidity. This study was initiated to evaluate the impact of primary femoral IMN on coagulation-, fibrinolysis-, inflammatory- and cardiopulmonary responses in polytraumatized patients.MethodsTwelve adult polytraumatized patients with femoral shaft fractures were included. Serial blood samples were collected to evaluate coagulation-, fibrinolytic-, and cytokine activation in arterial blood. A flow-directed pulmonary artery (PA) catheter was inserted prior to IMN. Cardiopulmonary function parameters were recorded peri- and postoperatively. The clinical course of the patients and complications were monitored and recorded daily.ResultsMean Injury Severity Score (ISS) was 31 ± 2.6. No procedure-related effect of the primary IMN on coagulation- and fibrinolysis activation was evident. Tumor necrosis factor alpha (TNF-α) increased significantly from 6 hours post procedure to peak levels on the third postoperative day. Interleukin-6 (IL-6) increased from the first to the third postoperative day. Interleukin-10 (IL-10) peaked on the first postoperative day. A procedure-related transient hemodynamic response was observed on indexed pulmonary vascular resistance (PVRI) two hours post procedure. 11/12 patients developed systemic inflammatory response syndrome (SIRS), 7/12 pneumonia, 3/12 acute lung injury (ALI), 3/12 adult respiratory distress syndrome (ARDS), 3/12 sepsis, 0/12 wound infection.ConclusionIn the polytraumatized patients with femoral shaft fractures operated with primary IMN we observed a substantial response related to the initial trauma. We could not demonstrate any major additional IMN-related impact on the inflammatory responses or on the cardiopulmonary function parameters. These results have to be interpreted carefully due to the relatively few patients included.Trial RegistrationClinicalTrials.gov: NCT00981877

The pattern of the procedure-related hemodynamic and pulmonary effects did not differ significantly between the RIA and the TR groups. The RIA group had lower numbers (ns) of embolisms per square centimeter lung area than the TR group. After reaming with the TR device, two animals died of PEs, the first postoperative day. The patients with femoral shaft fracture and additional cardiopulmonary injury or preexisting reduced cardiopulmonary function, however, need special attention, and the use of RIA may, in these cases, represent a better operative alternative with a lesser operative burden.