Fluid management in trauma and burn Dr Osama Bawazir Assistant Professor , Consultant Pediatric surgeon FRCSI, FRCS(Ed), FRCS (glas), FRCSC, FAAP,FACS.

The initial treatment of seriously injured patients consists of : primary survey (ABCDEs) resuscitation secondary survey diagnostic evaluation definitive care.

Anatomy of body fluids: Total body water ( TBW) constitutes 50 – 70 % ( 42 L) of body weight. It is divided into 2 functional compartments; ECF & ICF.

Chemical composition of body fluid compartments Cations Plasma (mmol/L) ICF (mmol/L) Na+ 143 9 K+ 5 135 Ca2+ 1,3 <0,8 Mg2+ 0.9 25 Anions Cl- 103   HCO3- 24 HPO42- 0,4 74 Sulphate- 19 Protein 1,14 64

haemorrhage causes further reduction in intravenous volume fluid from the interstitial space is shifted to the intravascular space (autotransfusion)

Tissue injury results in SIR, release of mediators leading to increase in vascular permeability and tissue edema. A decrease in cardiac output and arterial O2 content leads to decreased O2 delivery

Fluid resuscitation can increase the interstitial edema, which is caused by the 'reperfusion injury' to the capillary interstitial membrane. This causes a rise in osmotic pressure in the extracellular spaces and glucose is primarily responsible for this. Tissue edema is rarely life-threatening but can decrease oxygenation, delay healing and can lead to subsequent sepsis

Management of Shock • Stop external bleeding • Administer fluid resuscitation – balanced salt solution at 20 ml/kg repeat as needed – Packed RBCs at 10 ml/kg • Surgery if condition remains unstable after fluid resuscitation

3 for 1 Rule a rough guideline for the total amount of crystalloid volume acutely is to replace each ML of blood loss with 3 ML of crystalloid fluid, thus allowing for restitution of plasma volume lost into the interstitial & intracellular space

* For adult 1-2 liters bolus Initial Fluid Therapy Lactated Ringer is preferred * For adult 1-2 liters bolus * For child 20ml/kg bolus with observation of response

The patient's response to this initial resuscitation determines subsequent therapy, 3 response patterns are described:  1. Rapid: Responds rapidly and remains hemodynamically stable.  2. Transient - Responds initially then deteriorates as fluids are decreased to maintenance levels.  3. Non-responsive: Failure to respond either to crystalloids or blood. 

Objectives of Fluid Replacement restoring adequate tissue perfusion and oxygen delivery as rapidly as possible

Vascular access • Peripheral IV • Central line • Intraosseus • Venous cutdown Poiseuille's Law The rate of flow is proportional to the fourth power of the radius of the catheter and the pressure gradient between the catheter opening and venous system and is inversely related to its length and fluid viscosity.

When to Give Fluid Became stander of care ….. …… to give as soon as possible. External control of hemorrhage should be obtained before restoring circulating volume. The administration of IV fluid should not delay transportation to hospital

What should we use? Lactated Ringers Normal Saline colloids Hypertonic Blood Substitutes Infusion of a balanced salt solution is the current standard of care with the initial bolus, as per Advanced Trauma Life Support guidelines, given "as rapidly as possible"

crystalloid These can be isotonic or hypertonic the major disadvantage of isotonic crystalloids is their limited ability to remain within the intravascular space LR by the end of a 1 liter infusion expands the intravascular compartment by only 194 ml the remaining 80% of fluid is lost to the intersitial space

Colloids A colloid is a fluid, containing particles that are large enough to exert an oncotic pressure across the microvascular membrane greater ability to than crystalloids to remain within the intravascular   space and therefore more efficient volume expanders. approximately 90% of exogenous albumin can be found in the IV space 2 hrs after administered. the serum half life of albumin is about 18 hrs. synthetic colloids such as (hetastarch, hespan) have similar volume expanding abilities

Crystalloids versus colloids There are no prospective randomized controlled trials with adequate power to detect a difference in survival as the primary endpoint. in comparison with colloid, larger volumes of crystalloid are required to restore intravascular volume. Colloids can cause anaphyllactoid reactions and impair coagulation .

Others Albumin Hypertonic saline solutions Hemoglobin solutions

Blood Transfusion the best resuscitation fluid volume expansion and also transports oxygen The major reasons for transfusing blood and blood products in trauma are 1. Improvement of oxygen transport 2. restoration of red cell mass 3. correction of bleeding caused by platelet dysfunction 4. correction of bleeding caused by factor deficiencies. 

Transfusion with Disadvantages: 'O' Rh negative type specific blood Cross matchblood Disadvantages: cross-matched Massive transfusion can produce dilutional coagulopathy, hypocalcemia and hypomagnesemia. Blood-borne viral pathogens may be transfused.

Thermal protection. Fluids should be stored at body temperature and blood products should be administered through rapid-warming devices. When examination is completed, the patient should covered with warm blankets or other devices until body temperature returns to normal.

Hypothermia following a major trauma increase mortality and has a number of adverse effects: Oxyhemoglobin dissociation curve is shifted to the left which impairs peripheral oxygen unloading. Shivering will compound the lactic acidosis that accompanies hypovolemia. Hypothermia increases bleeding by dilutional coagulopathy. Hypothermia increases the risk of infection. Hypothermia increases the risk of cardiac morbid events

End points of Resuscitation Coroner stone of trauma management Control of bleeding restoration of circulating blood volume providing adequate oxygenation at the cellular level No single end point has found to be sufficient by itself

Patients who have a good response to fluid infusion, i. e Patients who have a good response to fluid infusion, i.e., normalization of vital signs, clearing of the sensorium, evidence of good peripheral perfusion (warm fingers and toes with normal capillary refill) are presumed to have adequate perfusion. Urine output is a quantitative and relatively reliable indicator of organ perfusion. Adequate urine output is 0.5 mL/kg/h in an adult, 1 mL/kg/h in a child, and 2 mL/kg/h in an infant less than 1 year of age.

the metabolic acidosis seen in the early phase of the resuscitation of the trauma pt is due to poor tissue perfusion and will reverse with adequate volume has been restored

BP, HR, urine output, mental status, pulse oximeter and capnogram are all used but will not reflect the situation at the cellular metabolic level aggressive monitors have been shown to improve mortality especially in elderly patients like the

CVP pulmonary artery occlusion pressure cardiac index oxygen consumption oxygen delivery base deficit Serum lactate Organ specific monitoring e.g: measuring intra-mucosal (gastric mucosal) pH

Elevating blood pressure is always a good thing Assumption Elevating blood pressure is always a good thing

May Be NOT

Elevating blood pressure in uncontrolled hemorrhage Acceleration of hemorrhage Mechanical clot disruption Dilution of clotting factors Permissive hypovolemia or Hypotensive resuscitation

Recommendations when intravenous fluid is indicated in the prehospital setting, crystalloid solutions should be the routine choice. Transfer to hospital should not be delayed by attempts to administer intravenous fluid. Fluid therapy should be titrated against response to guard against over resuscitation. Blood pressure targets could be established, that will maintain better systemic perfusion and reduce the risks of causing further hemorrhage (systolic blood pressure of 80 mm Hg is appropriate for tissue perfusion and minimizing hemorrhage).

BURNS Burn shock is hypovolemic and cellular in nature, and is characterized by decreased cardiac output, extracellular fluid and plasma volume oliguria. As with other forms of shock, the primary goal is to restore and preserve tissue perfusion

Referral to Burn Center * 2nd or 3rd degree burn >10% BSA, pt under 10 or over 50y/o * 2nd or 3rd degree burn > 20% BSA in other age group * 2nd or 3rd degree burn of face/eye/ear/hands/feet/ genitalia/perineum or major joints * 3rd degree burn >5% in any age group * Significant electrical/lightning injury * Significant chemical burn * Inhalation injury

Fluid Therapy in 2nd or 3rd Degree Burn Total amount of first 24 hours: 4 ml of Ringer lactate x BW(kg) x BSA * give 1/2 in first 8 hrs * 1/2 in remaining 16 hrs

Regardless of the resuscitation formula or strategy used, the first 24-48 hours require frequent adjustments. The quantity of crystalloid needed is dependent upon the parameters used to monitor resuscitation. Considerably more fluid will be needed, and more edema will result.

In patients with massive burns, young pediatric patients, and burns complicated by severe inhalation injury, a combination of fluids can be used to achieve the desired goal of tissue perfusion while minimizing edema. In these patients, the regimen of modified hypertonic (lactated Ringer's + 50 meq NaHCO3) saline fluid containing 180 meq Na/L is used for the first 8 h.

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