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) When to give fluid What is the appropriate type of fluid to be given How much to be administrated Special situations

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

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

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

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

This was the CT abd with contrast !!!

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

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

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

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

3- Hypovolemic Shock (Hemorrhagic) Manifestations:

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

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

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.

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

Type ? Amount ? Limit ?

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,Hct21-----Syst 110 mmHg ( 3-4 L) (If + head injury-----Syst 90 mmHg)

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

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 < 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)

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

Acidosis  Coagulopathy Hemorrhage  Massive transfusion Hypothermia Acidosis  Coagulopathy