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FLUID RESUSCITATION

FLUID RESUSCITATION. CURRENT THINKING Dr Sean R Santos CGH. Objectives. Define Shock Consider methods for recognising the shocked casualty Discuss pre-hospital management In-hospital Management Future Developments. Shock.

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FLUID RESUSCITATION

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  1. FLUID RESUSCITATION CURRENT THINKING Dr Sean R Santos CGH

  2. Objectives • Define Shock • Consider methods for recognising the shocked casualty • Discuss pre-hospital management • In-hospital Management • Future Developments

  3. Shock Failure to achieve adequate perfusion and oxygenation of the tissues

  4. Types of shock • Hypovolaemic • Cardiogenic Inc Tamponade/Tension • Septic • Neurogenic • Anaphylactic

  5. Hypovolaemic Shock

  6. Class I 750 mL (15%) • Slightly anxious • Normal blood pressure • Heart rate < 100 / min • Respirations 14-20 / min • Urinary output 30 mL / hour • Warm skin, Normal Cap Refill

  7. Class II 750-1500 mL (15-30%) • Anxious • Normal blood pressure • Heart rate > 100 / min • Decreased pulse pressure • Respirations 20-30 / min • Urinary output 20-30 mL / hour • Pale, Cool, Cap Refill Delayed

  8. Class III 1500-2000 mL (30-40%) • Confused, anxious • Decreased blood pressure • Heart rate > 120 / min • Decreased pulse pressure • Respirations 30-40 / min • Urinary output 5-15 mL / hour • V. Pale, Sweaty, Cap refill V Delayed

  9. Class IV >2000 mL (>40%) • Confused, lethargic • Hypotension • Heart rate > 140 / min • Decreased pulse pressure • Respirations >35 / min • Urinary output negligible

  10. Pulses • Radial 70-80 mmHg • Femoral 60-70 mmHg • Carotid ≤60 mmHg

  11. Early Indicators • Resp Rate • Colour • Cap refill • Mental State

  12. Management Historical New Strategies

  13. Historical • Two Large Bore Cannulae • Two Litres Of Fluid • Continue Replacement until HR Normal • Control Bleeding

  14. New Strategies Preservation Bleeding Control Fluid Management

  15. Preservation • Rapid Transfer • Surgical/Radiological Management of Bleeding • Permissive Hypotension • Immobilisation of Fractures • Gentle Handling to preserve Clot

  16. PreservationVisible Haemorrhage • Direct Pressure • Indirect Pressure • Tourniquet

  17. Tourniquet

  18. Tourniquets • Proximal • Adequate Pressure • Communication, Orange for Visibility • Aim for max 2 hours • Adequate facilities on release

  19. Clot Promotion • Quick Clot • Dressings • Fibrin Sealants

  20. Pelvic Slings

  21. Fluid Management • Isotonic Fluids • Colloids • Hypertonic Fluids

  22. Stay in circulation Plasma Expand May disrupt Clotting Direct and Dilutional Anaphylaxis ? Cellular acidosis Lesser Volume All fluid compartments No direct effect on Clotting ? Cellular function better preserved Greater volume c. X3 Colloids vs. Crystalloids

  23. Not What How Much

  24. How Much • Pulse Nothing • No pulse 250ml Bolus ? Response ? Repeat • Unconscious Measure BP ≤100 mmHg 250ml ≥100 mmHg Nothing

  25. Route • Big IV Cannula • Intra Osseous

  26. Current/Future Developments • Hypertonic Solutions • Damage Control Resuscitation • Damage Control Surgery

  27. Hypertonic Solutions • 5, 7.5, 10%Saline • +/- Colloid • Rapid, Sustained BP increase • Small Volume • Diuresis • ↓ Intracranial Pressure

  28. Damage Control Resuscitation Damage Control Surgery

  29. Damage Control Resuscitation • Lethal Triad Hypothermia Acidosis Coagulopathy

  30. Damage Control Resuscitation • Permissive Hypotension • Haemostatic Resuscitation • Damage Control Surgery

  31. Haemostatic Resuscitation • Packed Cell 1unit • FFP 1unit • Platelets 1 bag/4-6 • Calcium, Tranexamic Acid, Factor VIIa

  32. Damage Control Surgery

  33. ?

  34. Conclusions Recognition Preservation Small Volume Resuscitation Control Of Bleeding

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