Acute care services are increasingly faced with the double burden of high patient acuity and limited resources. Early identification of patients who are sick or who have the potential to deteriorate rapidly is crucial so that these resources may be allocated to those in greatest need. Traditional measures of illness and end points of resuscitation, such as vital signs, often fail to identify occult hypoperfusion with certain disease processes associated with high morbidity and mortality. Thus, biochemical markers that may predict illness earlier are becoming more relevant. We present a review of the evidence behind use of the serum lactate level in this setting.

Penetrating craniofacial trauma, although uncommon, has a high potential for death or serious morbidity from injury to vital neurovascular structures. An in situ facial foreign body, particularly if large, presents significant challenges beyond safe and timely removal. Airway management, stabilization of the object, management of increased intracranial pressure, and identification of injuries to local structures are all issues that may require addressing. We present a case of penetrating facial trauma from a vice clamp, with an in situ foreign body, that illustrates several of these challenges and provides a forum for their discussion. RÉ SUMÉLe traumatisme craniofacial pé né trant, bien qu'il soit rare, pré sente un potentiel é levé de dé cè s ou de morbidité grave en raison de l'atteinte aux structures neurovasculaires vitales. Un corps é tranger in situ au niveau du visage, en particulier s'il est gros, pré sente des dé fis importants hormis son retrait sû r et en temps opportun. La prise en charge des voies respiratoires, la stabilisation de l'objet, la gestion de la pression intracrâ nienne accrue et la dé termination de la pré sence de lé sions aux structures locales sont autant de questions qui devront ê tre ré solues. Nous pré sentons un cas de traumatisme pé né trant au visage causé par un serre-joint, avec un corps é tranger in situ, qui illustre plusieurs de ces dé fis et fournit un forum pour la discussion.

Clinical questionDoes giving tranexamic acid to trauma patients who are actively bleeding or at risk for significant hemorrhage have an impact on mortality? Article chosen CRASH-2 Trial Collaborators. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet 2010;376:23-32. Objective The study collaborators sought to evaluate the effect of tranexamic acid on mortality in trauma patients who were actively bleeding or at risk for significant hemorrhage. Secondary outcomes included the incidence of vascular occlusive events and the number of blood transfusions required.