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
Rt hypochondrial 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 Rt hypochondrium
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
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., Tibial tuberosity , 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)
(permessive hypot.)
Blood loss>30%-----Colloids and/or Packed RBCs(conservative strategy:Hb7,Hct 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

21. 1- Haemostatic Resuscitation
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 < or < in major trauma)
Procoagulant therapy:
Novoseven mic/Kg over 2 hrs / 2 hrs
Proth Complex Conc.(2,7,8,9,10,prot C)

22. 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

23. Acidosis  Coagulopathy
Hemorrhage 
Massive transfusion
Hypothermia
Acidosis  Coagulopathy