Commentary

Vollständiger Titel Bd. 4: TheMassorah translated into English with a critical & exegetical commentary /by Christian D. Ginsburg

Detection of haemorrhagic shock: Are vital signs obsolete? A commentary by Dr M. Luginbühl

The ATLS program by the American college of surgeons is probably the most important globally active training organization dedicated to improve trauma management. Detection of acute haemorrhagic shock belongs to the key issues in clinical practice and thus also in medical teaching. (In this issue of the journal William Schulz and Ian McConachrie critically review the ATLS shock classification Table 1), which has been criticized after several attempts of validation have failed [1]. The main problem is that distinct ranges of heart rate are related to ranges of uncompensated blood loss and that the heart rate decrease observed in severe haemorrhagic shock is ignored [2]. Table 1. Estimated blood loos based on patient's initial presentation (ATLS Students Course Manual, 9th Edition, American College of Surgeons 2012). Class I Class II Class III Class IV Blood loss ml Up to 750 750–1500 1500–2000 >2000 Blood loss (% blood volume) Up to 15% 15–30% 30–40% >40% Pulse rate (BPM) <100 100–120 120–140 >140 Systolic blood pressure Normal Normal Decreased Decreased Pulse pressure Normal or ↑ Decreased Decreased Decreased Respiratory rate 14–20 20–30 30–40 >35 Urine output (ml/h) >30 20–30 5–15 negligible CNS/mental status Slightly anxious Mildly anxious Anxious, confused Confused, lethargic Initial fluid replacement Crystalloid Crystalloid Crystalloid and blood Crystalloid and blood Table options In a retrospective evaluation of the Trauma Audit and Research Network (TARN) database blood loss was estimated according to the injuries in nearly 165,000 adult trauma patients and each patient was allocated to one of the four ATLS shock classes [3]. Although heart rate increased and systolic blood pressure decreased from class I to class IV, respiratory rate and GCS were similar. The median heart rate in class IV patients was substantially lower than the value of 140 min−1 postulated by ATLS. Moreover deterioration of the different parameters does not necessarily go parallel as suggested in the ATLS shock classification [4] and [5]. In all these studies injury severity score (ISS) and mortality increased with in increasing shock class [3] and with increasing heart rate and decreasing blood pressure [4] and [5]. This supports the general concept that the higher heart rate and the lower blood pressure, the sicker is the patient. A prospective study attempted to validate a shock classification derived from the ATLS shock classes [6]. The authors used a combination of heart rate, blood pressure, clinically estimated blood loss and response to fluid resuscitation to classify trauma patients (Table 2) [6]. In their initial assessment of 715 predominantly blunt trauma patients 78% were classified as normal (Class 0), 14% as Class I, 6% as Class II and only 1% as Class III and Class IV respectively. This corresponds to the results from the previous retrospective studies [4] and [5]. The main endpoint used in the prospective study was therefore presence or absence of significant haemorrhage, defined as chest tube drainage >500 ml, evidence of >500 ml of blood loss in peritoneum, retroperitoneum or pelvic cavity on CT scan or requirement of any blood transfusion >2000 ml of crystalloid. Because of the low prevalence of class II or higher grades statistical evaluation was limited to a comparison between Class 0 and Class I–IV combined. As in the retrospective studies, Lawton did not find a statistical difference of heart rate and blood pressure among the five groups either, although there was a tendency to a higher heart rate in Class II patients. Apparently classification during primary survey did not rely on vital signs but considered the rather soft criterion of “clinical estimation of blood loss” and requirement of fluid substitution. This suggests that allocation of an individual patient to a shock classification was probably more an intuitive decision than an objective calculation the shock classification. Nevertheless it was a significant predictor of ISS [6]. Table 2. Shock grade categories in prospective validation study (Lawton, 2014) [6]. Normal No haemorrhage Class I Mild Class II Moderate Class III Severe Class IV Moribund Vitals Normal Normal HR > 100 with SBP >90 mmHg SBP < 90 mmHg SBP < 90 mmHg or imminent arrest Response to fluid bolus (1000 ml) NA Yes, no further fluid required Yes, no further fluid required Requires repeated fluid boluses Declining SBP despite fluid boluses Estimated blood loss (ml) None Up to 750 750–1500 1500–2000 >2000 Table options What does this mean for clinical practice and medical teaching? All these studies illustrate the difficulty to validate a useful and accepted physiologic general concept of the response of the organism to fluid loss: Decrease of cardiac output, increase of heart rate, decrease of pulse pressure occurring first and hypotension and bradycardia occurring only later. Increasing heart rate, increasing diastolic blood pressure or decreasing systolic blood pressure should make any clinician consider hypovolaemia first, because it is treatable and deterioration of the patient is preventable. This is true for the patient on the ward, the sedated patient in the intensive care unit or the anesthetized patients in the OR. We will therefore continue to teach this typical pattern but will continue to mention the exceptions and pitfalls on a second stage. The shock classification of ATLS is primarily used to illustrate the typical pattern of acute haemorrhagic shock (tachycardia and hypotension) as opposed to the Cushing reflex (bradycardia and hypertension) in severe head injury and intracranial hypertension or to the neurogenic shock in acute tetraplegia or high paraplegia (relative bradycardia and hypotension). Schulz and McConachrie nicely summarize the various confounders and exceptions from the general pattern and explain why in clinical reality patients often do not present with the “typical” pictures of our textbooks [1]. ATLS refers to the pitfalls in the signs of acute haemorrhage as well: Advanced age, athletes, pregnancy, medications and pace makers and explicitly state that individual subjects may not follow the general pattern. Obviously the ATLS shock classification which is the basis for a number of questions in the written test of the ATLS students course and which has been used for decades probably needs modification and cannot be literally applied in clinical practice. The European Trauma Course, another important Trauma training program uses the same parameters to estimate blood loss together with clinical exam and laboratory findings (e.g. base deficit and lactate) but does not use a shock classification related to absolute values. In conclusion the typical physiologic response to haemorrhage as illustrated by the ATLS shock classes remains an important issue in clinical practice and in teaching. The estimation of the severity haemorrhage in the initial assessment trauma patients is (and was never) solely based on vital signs only but includes the pattern of injuries, the requirement of fluid substitution and potential confounders. Vital signs are not obsolete especially in the course of treatment but must be interpreted in view of the clinical context. Conflict of interest None declared. Member of Swiss national ATLS core faculty.

Enlargement Agenda - Special focus on Macedonia, Serbia and Kosovo. CEPS Commentary, 27 March 2013

This CEPS Commentary notes that this is a critical time for the EU’s enlargement agenda with competing interests at play – between those who suggest that further enlargement is a heavy burden that the EU can ill afford in the current economic climate, and others who continue to believe that extending the frontiers of peace and security to include the Balkan countries will make the EU a safer place. To counter the naysayers, Erwan Fouéré underlines the importance for the EU to show that its current strategy continues to deliver dividends, as it certainly does in the case of Kosovo and Serbia. He further advises the EU to be ready to adapt its strategy where necessary, as in the case of Macedonia, by using whatever leverage it has in a more direct and consistent way and ensuring that its policy objectives and strategy in this area are based on the progress assessment narrative and not the other way around. In his view, opening accession negotiations with Macedonia will be the only way to prevent the country from sinking into further political instability.

A Financial Markets Policy for the next 5 years. CEPS Commentary, 1 October 2014

Karel Lannoo prefaces his survey of the priorities for the new European Commission in the area of financial markets with a warning that the hangover from the past five years is huge and that public opinion on the role of the financial sector will continue to be critical for some time to come. Implementation and enforcement will need to be followed-up carefully, as any flaws could rapidly attract negative headlines. In this commentary, he finds that three themes stand out: moving back to normal in financial markets regulation, adequate implementation and enforcement, and access to finance. The latter, in particular, should be the overarching theme, in all its dimensions -- access to credit for SMEs, access to capital markets for new ventures and access to finance for households.

The German reaction to the Russian-Ukrainian conflict- shock and disbelief. OSW Commentary No. 132, 03.04.2014

The crisis in Ukraine and the Russian intervention have brought about a situation in which it is necessary for Germany to make decisions and take action. No one in Berlin was prepared for this nor did anyone want this to occur. The effect of this is that the government has adopted a clearly critical stance on Russia, albeit in tandem with cautious diplomatic moves; it has given its consent to limited sanctions on representatives of the Russian elite, and has disapproved of economic sanctions. On the other hand, voices have been heard in the political debate in Germany not only warning of the catastrophic consequences of a deterioration in German-Russian relations but also those in fact expressing understanding for the Russian reaction. Although it is typical above all of the business circles engaged in Russia and the authors of Germany’s Ostpolitik to downplay the Kremlin’s moves, political parties and the German public are divided over how Germany should respond to Moscow’s policy, and this dispute will worsen. Berlin will take a whole array of actions to de-escalate the conflict, since the imposition of radical political and economic sanctions on Russia would also have a strong adverse effect on Germany. As regards sanctions, Germany would not only sustain economic losses, but they would also undermine the ideological foundations for the still popular vision for Germany’s strategy towards Russia in which great emphasis is laid on a strong “respect for the EU’s most important neighbour and its interests”.

No other choice but co-operation. The background of Lithuania's and Latvia's relations with Belarus. OSW Commentary No. 99, 2013-01-04

For years now Belarus has been a key economic partner for Lithuania and Latvia. These two Baltic states have well-developed port infrastructure and thus provide what are the geographically closest and also the cheapest exit to international outlets for Belarusia’s petrochemical and chemical industries, both of which are export-oriented. As a result, the transit of Belarusian goods is one of the major sources of income for the state budgets of the two countries. This economic interdependence has affected the stance Riga and Vilnius take on Minsk at the EU forum. When in February and March 2012 the Council of the European Union was resolving the issue of imposing economic sanction on selected Belarusian companies which backed Alyaksandr Lukashenka’s regime, this triggered a discussion on what the point of such measures is and on possible economic losses in Lithuania and Latvia. As a result of firm resistance from Latvia (which was backed by Slovenia), the Council removed those companies which were most strongly engaged in co-operation with Latvian partners from the list of those to be covered with economic sanctions. Lithuania, which is more critical of the political situation in Belarus, did not express its official opposition to the sanctions. Despite some differences in the policies adopted by Riga and Vilnius, it turned out that Minsk could count on strong support from local business groups in both of these countries, as these groups fear impediments in this highly profitable co-operation and also retaliation from the Belarusian government. The existing economic bonds mean that neither Vilnius nor Riga have any other choice but to co-operate with Belarus. They must therefore adopt a carefully balanced policy towards Minsk. At the same time, being EU member states, they do not officially deny that a problem exists with the violation of human rights by Alyaksandr Lukashenka’s regime. It is for this reason that the governments of Latvia and Lithuania will be interested in maintaining the status quo in relations with Minsk. On the other hand, Belarus in a way also has no other choice but to use the ports in Lithuania and Latvia, and this will prevent it from excessively escalating tension in relations with these two countries.

The press and freedom of speech in Ukraine ahead of parliamentary elections. OSW Commentary No. 90, 2012-09-20

The independence of the mass media has been regularly restricted over the past two years in Ukraine. Following a period of relative freedom in 2005–2010, the scope of direct and indirect government control of the press has increased, cancelling out the achievements of the Orange Revolution in this area. The press in Ukraine is less and less able to perform its role as watchdog on the government and politicians and as a reliable source of information on the situation in the country to the public. This is mainly due to: (1) the concentration of the most important mass media in the hands of Ukraine’s most powerful oligarchs, whose business interests depend on the government; (2) the use of the press as instruments in political and business competition; (3) the ruling class’s subordination of the institutions which supervise the press; (4) repression used against media critical of the government and (5) the lack of an independent public broadcasting corporation. As a consequence, the press has hardly any impact on the political processes taking place ahead of the parliamentary election scheduled for 28 October. This is also an effect of a passiveness present in the Ukrainian public, who are tired of politics and are focused on social issues. Cases of abuse or corruption scandals revealed by the press do not provoke any response from the public and are rarely investigated by the public prosecution authorities. The more popular a given medium is, the more strongly it is controlled by the government. At present, television has to be recognised as the least reliable of the mass media. In turn, Internet news journals are characterised by the greatest pluralism but also have more limited accessibility. The political conditions in which the mass media operate in Ukraine lead to various forms of pathology. The most serious of them are censorship by the owners and self-censorship performed by journalists, and a great share of political advertorials. As the parliamentary election is approaching, the pathologies of the Ukrainian media market have been showing up with greater intensity.

Turkey and the EU: A play in search of a script. EuropEos Commentary No. 5, 28 September 2010

This Commentary warns that by continuing to act as if Turkey’s membership of the EU was still a credible prospect, the EU is dodging the critical issue of how to establish friendly and constructive relations with an independent, self-confident Turkey. More importantly, this approach prevents the EU from at last accepting that enlargement is not the only – nor necessarily the best – policy option available to deal effectively with a strategically important country on its borders.

The role of politicians in inciting financial markets to attack the eurozone. EuropEos Commentary No. 4, 21 June 2010

While acknowledging that the sustainability of sovereign debt is a serious issue that must be confronted, this EuropEos Commentary finds that financial markets have blown the problem completely out of proportion, leading to a full-scale confidence crisis. The authors present evidence suggesting that politicians’ public disagreements and careless statements at critical junctures may have added oil to incipient fire. By creating the impression that domestic political interests would take precedence over orderly management of the Greek debt crisis, they raised broader doubts about their ability to address fundamental economic divergences within the area, which are the real source of debt sustainability problems in the medium term.

Critical health psychology - Who benefits?

This commentary deals with two issues raised by Hepworth (this issue). Concerning definitions, it argues that critical health psychology needs to be more explicit in defining itself as politically left-wing, and that its central defining characteristic should be that it is research and practice which aims primarily to benefit the participants, regardless of any specific method or epistemology. Concerning the value of critical health psychology, it argues that work which has improved health on a global scale and which aims to reduce inequities is being done, but not by critical psychologists, and suggests a need for more action and less rhetoric.

Symposium commentary : reflections on the theory of deliberative systems

Autoethnography : critical appreciation of an emerging art

In this article, the author discusses how she applied autoethnography in a study of the design of hypermedia educational resources and shows how she addressed problematic issues related to autoethnographic legitimacy and representation. The study covered a 6-year period during which the practitioner’s perspective on the internal and external factors influencing the creation of three hypermedia CD-ROMs contributed to an emerging theory of design. The author highlights the interrelationship between perception and reality as vital to qualitative approaches and encourages researchers to investigate their reality more fully by practicing the art of autoethnography.