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Fluid Resuscitation in Trauma By/ Hany Maher

Fluid Resuscitation in Trauma By/ 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)

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Fluid Resuscitation in Trauma By/ Hany Maher

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  1. Fluid Resuscitation in Trauma By/ 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

  2. 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

  3. 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 Rthypochondrial pain, contusions & difficult breathing • After full survey: # Rt Tibia #Rt 12 Rib • 1hr later , despite Fluid administration: worsened vital signs DLC

  4. What is the cause of Shock in this patient ? -Hypovolemic -Distributive( neurogenic, anaphilactic..) -Cardiogenic -Obstructive

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

  6. If in addition: Exaggerated pain in Rthypochondrium Key: from the Pelvi-abd U/S… Creat. stat

  7. This was the CT abd with contrast !!!

  8. 1- Approach to Trauma patient Preparation: notification, prepare place Triage: Color code 1ry Survey: A B C D E Resuscitation: Oxygen 2 wide bore canulae (16G) Fluid Resuscitation Adjuncts: Preg test-U. cath

  9. 6.2ry Survey: Hist.(AMPLE)& Head to toe exam 7.Adjuncts: Special survey 8. Post resusc. reeval.: S&S-UOP 9. Definitive care

  10. 2- Shock in Trauma ptn. Inadequate tissue perfusion… Types: Hypovolemic : the most common Destributive : neurogenic, vasogenic Obstuctive : Tamponade Cardiogenic: Acute MI

  11. Apnea Aortic/ Heart rupture Epidural/ Subdural hematoma Cardiac tamponade Haemo/ Pneumothorax Intra-abdominal bleeding (Spleen, Liver) Pelvic fractures Multiple injuries with significant blood loss Sepsis Multiple organ failure

  12. 3- Hypovolemic Shock (Hemorrhagic) Manifestations:

  13. 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>2 Lact. Acidosis>2.5

  14. Till Now we have discussed: Approach to trauma ptn Types of Shock in Trauma ptn Hypovolemic shock

  15. 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.

  16. 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., Tibialtuberosity , Epidural needle Central Line: not in the protocol, If needed---Femoral

  17. Type ? Amount ? Limit ?

  18. 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) (permessivehypot.) Blood loss>30%-----Colloids and/or Packed RBCs(conservative strategy:Hb7,Hct21-----Syst 110 mmHg ( 3-4 L) (If + head injury-----Syst 90 mmHg)

  19. 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

  20. Special Remarks: 1- Haemostatic Resuscitation • Permessivehypot. • 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)

  21. 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

  22. Hemorrhage  Massive transfusion  Hypothermia Acidosis Coagulopathy

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