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Fluid Resuscitation in Trauma By/ Hany Maher References: Manual of Advanced Trauma lifesupport course; 5:45-52, 2010. References: Manual of Advanced Trauma.

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Presentation on theme: "Fluid Resuscitation in Trauma By/ Hany Maher References: Manual of Advanced Trauma lifesupport course; 5:45-52, 2010. References: Manual of Advanced Trauma."— Presentation transcript:

1 Fluid Resuscitation in Trauma By/ Hany Maher References: Manual of Advanced Trauma lifesupport course; 5:45-52, References: Manual of Advanced Trauma lifesupport course; 5:45-52, Emergency war surgery; 6:1-10, 2008 Emergency war surgery; 6:1-10, 2008 Protocol of management of critical cases;1-30,2008 Protocol of management of critical cases;1-30,2008

2 Objectives Approach to a traumatized patient ( revision)Approach to a traumatized patient ( revision) When to give fluidWhen to give fluid What is the appropriate type of fluid to be givenWhat is the appropriate type of fluid to be given How much to be administratedHow much to be administrated Special situationsSpecial situations

3 Case Report (main items) Female patient 45 years oldFemale patient 45 years old Presented to the ER post RTA 1 hr agoPresented to the ER post RTA 1 hr ago Medically free by historyMedically free by history S & S: HR 120b/min, Bl pr 80/40 mmHg,Sweating, drowsyS & S: HR 120b/min, Bl pr 80/40 mmHg,Sweating, drowsy Rt leg pain and disability Rt leg pain and disability Rt hypochondrial pain, contusions & difficult breathing Rt hypochondrial pain, contusions & difficult breathing After full survey: # Rt TibiaAfter full survey: # Rt Tibia #Rt 12 Rib #Rt 12 Rib 1hr later, despite Fluid administration: worsened vital signs1hr later, despite Fluid administration: worsened vital signs DLC DLC

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

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

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

7 This was the CT abd with contrast !!!

8 1- Approach to Trauma patient 1.Preparation: notification, prepare place 2.Triage: Color code 3.1ry Survey: A B C D E 4.Resuscitation: Oxygen 2 wide bore canulae (16G) Fluid Resuscitation 5.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…Inadequate tissue perfusion… Types: Hypovolemic : the most commonTypes: Hypovolemic : the most common Destributive : neurogenic, vasogenic Destributive : neurogenic, vasogenic Obstuctive : Tamponade Obstuctive : Tamponade Cardiogenic: Acute MI 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:Manifestations:

13 Hypovolemic Shock (Hemorrhagic) Take Care :Tachycardia is not reliableTake 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) Then: + Cardiac C fibers---cause – VMC ↓Bl. Pr) So: ABG Base deficit>2So: ABG Base deficit>2 Lact. Acidosis>2.5

14 Till Now we have discussed: Approach to trauma ptnApproach to trauma ptn Types of Shock in Trauma ptnTypes of Shock in Trauma ptn Hypovolemic shockHypovolemic 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 EA B C D E Consider Hypovolemic shock untill proved otherwiseConsider Hypovolemic shock untill proved otherwise Stop or Decrease Bleeding:Stop or Decrease Bleeding: Pr points: Hand wrist Pr points: Hand wrist Arm-----axillaArm-----axilla Forearm------inner upper armForearm------inner upper arm Thigh-----below the groinThigh-----below the groin Leg----behind the kneeLeg----behind the knee 2 wide Bore Canulae (16G)2 wide Bore Canulae (16G) Interosseous: <6 years, Pr., Tibial tuberosity, Epidural needle Interosseous: <6 years, Pr., Tibial tuberosity, Epidural needle Central Line: not in the protocol, If needed---Femoral

17 Type ?Type ? Amount ?Amount ? Limit ?Limit ?

18 1-2L warmed lactated ringer,20ml/kg in child1-2L warmed lactated ringer,20ml/kg in child (no Dextrose 5%, no Vasopressors) Evaluation of degree of Blood loss: Difficult!!Evaluation of degree of Blood loss: Difficult!! Minimal Trauma( 30%)----Syst 70 mmHg (1-2L)Minimal Trauma( 30%)----Syst 70 mmHg (1-2L) (permessive hypot.) (permessive hypot.) Blood loss>30%-----Colloids and/or Packed RBCs(conservative strategy:Hb7,Hct Syst 110 mmHg ( 3-4 L)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)Hist & Exam( head to toe) Analgesia, Antibiotic, tetanus toxoid, antiemetic ( not IM)Analgesia, Antibiotic, tetanus toxoid, antiemetic ( not IM) Patient may be : Responder (regain Conc., palpable radial art., SBP>90, MAP>60)Patient may be : Responder (regain Conc., palpable radial art., SBP>90, MAP>60) Transient responder: Damage control surgery Transient responder: Damage control surgery Non responder: Urgent surgery Non responder: Urgent surgery

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21 Special Remarks: 1- Haemostatic Resuscitation Permessive hypot.Permessive hypot. Early use of Blood Transf.Early use of Blood Transf. But---remember the adv. of reduced Hct on the viscosity and flow of the bloodBut---remember the adv. of reduced Hct on the viscosity and flow of the blood ABO cross matching (10 min)-----O negativeABO cross matching (10 min)-----O negative 1 RBCs : 1 FFP + PLT (1 pack/ 10 kg if < or < in major trauma)1 RBCs : 1 FFP + PLT (1 pack/ 10 kg if < or < in major trauma) Procoagulant therapy:Procoagulant therapy: Novoseven mic/Kg over 2 hrs / 2 hrsNovoseven mic/Kg over 2 hrs / 2 hrs Proth Complex Conc.(2,7,8,9,10,prot C)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 Acute administration of > 0.5 Blood volume/hr

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

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