FLUID RESUSCITATION TRAUMA PATIENT Author; Prof.MEHDI HASAN MUMTAZ Consultant Intensivist/ Anaesthetist Christie Hospital,Manchester,U.K.

FLUID THERAPY  Questions 1,Does the pt.need fluids ? 2,How much he/she needs ? 3,What type of fluid is needed ?

STATUS OF HYDRATION  Intravascular Haemodynamics  Interstitial Skin fold  Intracellular thirst, confusion,coma,death confusion,convulsion,coma,death

FLUID RESUSCITATION  1. Prehospital phase  2. Hospital phase Resuscitative ( A&E) Operative (OR) Critical care (HDU,ICU)

PRE-HOSPITAL PHASE ;DILEMMA; Definitive Hmge control –No Inadequate Resus. -Mortality Full Resus. -Hmge

PREHOSPITAL PHASE  Two schools of thought Scoop & Run, Target, ;palpable pulse; Stay & Play, Necessitate, control bleeding ( Thoracotomy,Laparotomy)

PREHOSPITAL PHASE  Resuscitation Fluid 1 ;Colloid vs crystalloids; 2 ;Iso-osmolar/oncotic vs hyper-osmolar/oncotic; 3 ;Saline vs Lactated Ringer;

CONSENSUS VIEW Emergency Medicine Journal 2002;19; Revell M,Porter K,Greaves I.

FULL TEXT ;Fluids should not be administered to a trauma patient before haemorrhage control if radial pulse can be felt,if not,give boluses of fluid challenge(250 mls) till the pulse is palpable.Now Suspend fluid therapy & monitor the situation.;

Reference  Bickel WH, Wall MJ, Jr., Pepe PE,et al. Immediate versus delayed resuscitation for hypotensive patients with penetrating torso injuries.New England Journal of Medicine 1994;331:

TABLE VARIABLEIMMEDIATE R 309 DELAYED R 289 Before arrival at H Ringer lact. Ml TRAUMA CENTRE Ringer lact; Ml Packed red cells Operating room Ringer lact;Ml Packe3d red cells FFP ;Ml Rate of I/O infusion ml/min

TABLE variable immediate R 309 Delayed R 289 SBP HB g/dl PLT PT APTT PH HCO3 20+-

2- HOSPITAL PHASE  :Continuum from field: EXPERIENCE + EQUIPMENT ;The key is the time to control surgical haemorrhage;

2-HOSPITAL PHASE  Best available evidence based approach to furthure resuscitation in the same way as any other critically ill patient;  AIM; Restore full circulation and optimal perfusion of all tissues guided by monitoring

TYPES FLUIDS  COLLOIDS:- Efficient No edema Expensive Affect Co-agulation

TYPES OF FLUIDS  CRYSTALLOIDS:- Less expensive/unit Less efficient Cause oedema eg,Abdominal compartment syndrome

TYPES OF FLUIDS  0.9% SALINE VS R.LACTATE Hyper tonic Hypo tonic Acidoses Acidoses Redce R.Function No effect Reduce G.I.perfu- No effect -sion

TYPES OF FLUIDS  BLOOD & BLOOD PRODUCTS Expensive Availability O2 Delivery Coagulopathy correction Target > 10G /dl

RECOMMENDATIONS  0.9% SALINE, Resuscitation fluid of choice both in field & Hospital untill head injury is ruled out Lactated RINGER, For hydration in non head injured COLLOIDS, For volume resuscitation

TYPES OF FLUIDS HYPERTONIC & HYPER ONCOTIC SOLUTIONS PERFLUROCARBONS & STROMA FREE HAEMOGLOBIN SOLUTIONS ; ExpermentAL PRODUCTS;

SUCCESSFUL RESUSCITATION  REQUIRES:- ;early restoration of Heart-Lung- Brain circulation to avoid immediate death; 50% BV replacement required to restore a viable Heart-Lung-Brain circulation in non anaesthetised,non sedated patient 100% BV replacement to reperfuse all organs,especialy Splechnic bed

HOSPITAL PHASE - HDU/ICU Specialised care + Advanced monitoring + Multi-organ support

CONCLUSION 1,Restore pulse with boluses of Saline 2,Transfer to hospital,control bleeding,exclude head injury,then Ringer lactate for hydration and synthetic colloids for volume resuscitation. 3,Blood/products—early 4,Saline-choice for early Resus