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Despite conflicting data regarding its effectiveness, many massive transfusion protocols (MTPs) include recombinant Factor VIIa (rFVIIa) as an adjunct to hemorrhage control. Over a 3-year period, outcome data for massively transfused patients was compared based on administration of rFVIIa as part of a mature MTP. Of 228 MTP activations, 117 patients were candidates for rFVIIa, and, of these, 39 patients received rFVIIa under the MTP. Comparing patients who received rFVIIa with those who did not based on initial packed red blood cell (PRBC) transfusion requirements, there was no difference in mortality for transfusions ≤ 20 units (25 vs 24%, 24-hour; 25 vs 42%, 30-day) or 21 to 30 units (33 vs 47%, 24-hour; 55 vs 50%, 30-day). For initial requirement ≥ 30 units of PRBCs, 24-hour mortality (26 vs 64%, P = 0.02) was significantly decreased in patients that received rFVIIa (n = 19) compared with those who did not (n = 17). These mortality differences were not maintained at 30 days (68 vs 71%). rFVIIa had minimal clinical impact on outcomes for patients requiring less than 30 units of PRBCs. For patients transfused more than 30 units of PRBCs, differences in 24-hour and 30-day mortality suggest that rFVIIa converted early deaths from exsanguination to late deaths from multiorgan failure.

Trauma with resultant hypovolemic shock remains both prevalent and difficult to treat. Standard strategies using volume resuscitation and catecholamine support have historically yielded poor results. Vasopressin has emerged as a possible pharmacologic adjunct, particularly in patients with shock refractory to the administration of fluids and catecholamines. Much of the data regarding vasopressin is extrapolated from its usefulness in cases of nonhypovolemic human shock, which are supported by convincing animal studies. It is true that humans show a deficiency in vasopressin minutes after significant hemorrhage that can respond to administration of exogenous vasopressin. When given in physiological dosing regimens, vasopressin appears to be a safe adjunct to other therapy. Definite recommendations regarding indications for use, recommended dose, and long-term outcome in patients with hemorrhagic shock await a much needed prospective, randomized, controlled trial.

Temporary intravascular shunts (TIVS) are synthetic intraluminal conduits that maintain arterial and/or venous blood flow. This technique can be used for: 1) replantation; 2) open extremity fractures with extensive soft tissue and arterial injuries; or 3) damage control (extremity/truncal). The literature defining TIVS is composed exclusively of small case series (primarily penetrating injuries). Our goal was to identify the injured population who actually undergoes TIVS using the National Trauma Data Bank (2001 to 2005). TIVS were placed in 395 patients (mean Injury Severity Score = 26; initial hemodynamic instability = 24%; mean based deficit = -7.2; mortality = 14%). Blunt mechanisms caused 64 per cent (251 of 395) of cases. Penetrating injuries were primarily gunshot wounds (97%). Concurrent severe extremity fractures and/or soft tissue defects were present in 185 (74%) blunt-injured patients. Only six of 111 centers performing TIVS used this technique five or more times. Only three centers used TIVS more than 10 times. The volume of TIVS use was similar across the study period (P0.05). TIVS is primarily used in blunt motor vehicle collision trauma with concurrent severe extremity fractures and soft tissue injuries. This provides distal perfusion while surgeons assess/fixate the limb. TIVS are placed relatively uncommonly by a large number of trauma centers with a few hospitals using them much more frequently for penetrating injuries.

Historically, hepatic portal venous gas (HPVG) seen on abdominal radiographic examination indicated serious intra-abdominal pathology requiring urgent operative intervention. The mortality attributed to HPVG is associated closely with its causative source rather than a direct effect of the presence of venous air and, therefore, the finding should be correlated with a careful clinical examination before any therapeutic endeavor. Fourteen cases of HPVG associated with blunt trauma have been reported over the past 20 years, and only half of these have resulted in surgery. We report the case of a 24-year-old woman who presented with no abdominal pathology other than HPVG after a severe motor vehicle crash. She was managed nonoperatively and made a successful recovery.