Fluid Resuscitation in

TraumaBy/

Hany Maher References: Manual of Advanced Trauma lifesupport

course; 5:45-52, 2010. Emergency war surgery; 6:1-10, 2008 Protocol of management of critical cases;1-

30,2008

Objectives

• Approach to a traumatized patient ( revision)

• When to give fluid • What is the appropriate type of fluid

to be given• How much to be administrated• Special situations

Case Report(main items)

• Female patient 45 years old• Presented to the ER post RTA 1 hr ago• Medically free by history• S & S: HR 120b/min, Bl pr 80/40

mmHg ,Sweating, drowsy Rt leg pain and disability Rt hypochondrial pain, contusions & difficult breathing

• After full survey: # Rt Tibia #Rt 12 Rib

• 1hr later , despite Fluid administration: worsened vital signs

DLC

• What is the cause of Shock in this patient ?

-Hypovolemic-Distributive( neurogenic,

anaphilactic..)-Cardiogenic-Obstructive

• How can we differentiate ?-Insert a central line-Do further investigations-Intubate the patient-Give vasopressors

If in addition:

• Exaggerated pain in Rt hypochondrium

• Key: from the Pelvi-abd U/S…

Creat. stat

This was the CT abd with contrast !!!

1- Approach to Trauma patient

1. Preparation: notification, prepare place

2. Triage: Color code3. 1ry Survey: A B C D E4. Resuscitation: Oxygen

2 wide bore canulae (16G)

Fluid Resuscitation5. Adjuncts: Preg test-U. cath

6. 2ry Survey: Hist.(AMPLE)& Head to toe exam

7. Adjuncts: Special survey8. Post resusc. reeval.: S&S-UOP9. Definitive care

2- Shock in Trauma ptn.

• Inadequate tissue perfusion…• Types: Hypovolemic : the most

common Destributive : neurogenic,

vasogenic Obstuctive : Tamponade Cardiogenic: Acute MI

ApneaAortic/ Heart ruptureEpidural/ Subdural hematomaCardiac tamponadeHaemo/ PneumothoraxIntra-abdominal bleeding (Spleen, Liver)Pelvic fracturesMultiple injuries with significant blood loss

SepsisMultiple organ failure

3- Hypovolemic Shock (Hemorrhagic)

• Manifestations:

Hypovolemic Shock (Hemorrhagic)

• Take Care : Tachycardia is not reliable

Hypotension is late(30-40%)

(Occult Hypoperfusion Syndrome)

(Symp. Compensate till 30% in minor T.

Then: + Cardiac C fibers---cause – VMC-------↓Bl. Pr)

• So: ABG-------Base deficit>2Lact. Acidosis>2.5

Till Now we have discussed:

• Approach to trauma ptn• Types of Shock in Trauma ptn• Hypovolemic shock

4- Management of Shock in trauma ptn.A)General Rules:

-Warming: Hypothermia ↓BL pr, HR, RR

-Best Resuscit. Is in the Golden hr

- We aim to restore tissue Oxygenation not simply Bl pr.

B) 1ry Survey and Resuscitation

• A B C D E• Consider Hypovolemic shock untill proved

otherwise• Stop or Decrease Bleeding:

• Pr points: Hand-------wrist• Arm-----axilla• Forearm------inner upper arm• Thigh-----below the groin• Leg----behind the knee

• 2 wide Bore Canulae (16G) Interosseous: <6 years, Pr., Tibial tuberosity ,

Epidural needleCentral Line: not in the protocol, If needed---Femoral

•Type ? •Amount ?•Limit ?

• 1-2L warmed lactated ringer ,20ml/kg in child

(no Dextrose 5%, no Vasopressors)

• Evaluation of degree of Blood loss: Difficult!!

• Minimal Trauma( 30%)----Syst 70 mmHg (1-2L)

(permessive hypot.)• Blood loss>30%-----Colloids and/or Packed

RBCs(conservative strategy:Hb7,Hct21-----Syst 110 mmHg ( 3-4 L)

(If + head injury-----Syst 90 mmHg)

C) 2ry Survey

• Hist & Exam( head to toe)• Analgesia, Antibiotic, tetanus toxoid,

antiemetic ( not IM)• Patient may be : Responder(regain Conc.,

palpable radial art., SBP>90, MAP>60)

Transient responder: Damage control surgery

Non responder: Urgent surgery

Special Remarks:1- Haemostatic Resuscitation

• Permessive hypot.• Early use of Blood Transf.

• But---remember the adv. of reduced Hct on the viscosity and flow of the blood

• ABO cross matching (10 min)-----O negative

• 1 RBCs : 1 FFP + PLT (1 pack/ 10 kg if < 50.000 or <100.000 in major trauma)

• Procoagulant therapy: • Novoseven 30-120 mic/Kg over 2 hrs / 2 hrs• Proth Complex Conc.(2,7,8,9,10,prot C)

2- Massive Blood Loss

Def.: loss of one Bl volume over 24 hr, or

Loss of 50% of Bl volume over 3 hrs, or

Loss of 150 ml per minute

3- Massive Blood Transfusion

Def: replacement of the whole Blood voluume in <24 hrs

Acute administration of > 0.5 Blood volume/hr

Hemorrhage

Massive transfusion

Hypothermia

Acidosis Coagulopathy