Emergency Medicine Book

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Fluid Resuscitation in Trauma

Aka: Fluid Resuscitation in Trauma
  1. See Also
    1. Hemorrhage Management
    2. Massive Blood Transfusion
    3. Trauma Primary Survey
    4. Trauma Secondary Survey
    5. Pediatric Trauma
    6. ABC Management (Cardiopulmonary Resuscitation)
    7. Emergency Procedure
  2. Precautions
    1. Recognize signs of shock early
      1. Tachycardia
        1. See Heart Rate for normal ranges for age
        2. Early warning sign of shock in most cases
        3. Cold and tachycardic is shock until proven otherwise
        4. However can be misleadingly normal in cases of Delayed Tachycardia
      2. Avoid relying on late, unreliable markers of shock
        1. Hemoglobin And Hematocrit may not reflect massive blood loss for hours
        2. Blood Pressure does not fall until all compensatory Mechanisms are overwhelmed
    2. Promptly identify shock cause
      1. Most cases are Hemorrhagic Shock in the Trauma patient
        1. See Hemorrhagic Shock
        2. Emergent surgical Consultation
        3. Paramount to locate and stop the source of bleeding (and replace losses)
      2. Consider other forms of shock
        1. Tension Pneumothorax
        2. Cardiac Tamponade
        3. Neurogenic Shock secondary to spinal cord injury (not due to isolated intracranial injury)
  3. Indications: Signs of shock
    1. Mottled or pale color
    2. Cool skin
    3. Diminished peripheral pulses
    4. Delayed capillary pulses despite normal Ambient temp
    5. Mental status changes
    6. Oliguria
    7. Shock may be present despite normal Blood Pressure
  4. Preparations: Available Fluids for Volume Expansion
    1. Crystalloid Isotonic Solution
    2. Colloid Solution
    3. Blood Products
      1. Inadequate improvement after 2 crystalloid boluses (old recommendation)
      2. Newer guidelines as of 2013 suggest early transition to replacing blood loss with Blood Products
  5. Protocol: Fluid Replacement
    1. See Hemorrhagic Shock
    2. See precautions above
    3. Approach
      1. Initial fluid Resuscitation is with crystalloid
        1. Heated crystalloid (to 39 C or 102.2 F) is preferred to prevent Hypothermia
      2. Closely monitor for response to fluid Resuscitation
        1. Rapid and sustained response to fluid bolus (<10-20% blood loss)
          1. Monitor for decompensation (especially if risk of Delayed Tachycardia)
        2. Transient response to fluid bolus (20-40% blood loss, ongoing)
          1. Emergent Blood Transfusion
          2. Close monitoring for surgical intervention
        3. No response to fluid bolus (>40% blood loss)
          1. Emergent surgical or angiographic intervention
          2. Emergent Blood Transfusions (assume Massive Hemorrhage)
    4. Initial fluids - Replace first liter with crystalloid
      1. Isotonic crystalloid (Normal Saline and Lactated Ringers are equivalent) is standard of care
      2. Hypertonic Saline may be used instead (?antiinflammatory) but studies do not support benefit
        1. Bulger (2011) Ann Surg 253(3): 431-41
      3. Do not use dextrose solutions
        1. Induces osmotic diuresis
        2. Results in Hypokalemia
        3. Worsens ischemic brain injury
    5. Subsequent fluids (after first liter)
      1. Replace blood loss with Packed Red Blood Cells
      2. Massive Blood Transfusion is typically accompanied by platelet and Plasma Transfusion
        1. See Massive Blood Transfusion
    6. References
      1. Inaba and Herbert in Majoewsky (2013) EM:Rap 13(7): 4
  6. Monitoring: General
    1. See Central Venous Pressure (CVP)
    2. Inferior Vena Cava Ultrasound for Volume Status
    3. Reassess systemic perfusion after each bolus
      1. Urinary output
      2. Level of Consciousness
      3. Peripheral perfusion
      4. Blood Pressure
        1. Do not rely solely on blood presure as a marker of improvement (may simply reflect Vasoconstriction)
      5. Heart Rate
    4. Move swiftly to replacement of Blood Products if no response to Intravenous Fluids
    5. Large volume replacement is not a substitute for identifying and stopping active Hemorrhage
  7. Dosing
    1. Bolus Volumes given rapidly (<20 minutes)
      1. Adult: 1-2 Liter Bolus IV
      2. Child: 20 ml/kg LR or NS IV or IO
        1. Use 35-50 cc syringe attached to inline 3-way stop-cock
    2. Repeat dosing
      1. Assume Hemorrhagic Shock and replace with Blood Products
      2. May require 2-3 boluses within first hour until Blood Products
        1. Septic Shock is rare in Trauma, but may require 4 boluses in first hour
  8. References
    1. (2012) ATLS Manual, 9th ed, American College of Surgeons

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