1. Fluid Maintenance CPT James R. Rice, PA-C Program Manager Tactical Combat Medical Care

2. COMBAT FLUID RESUCITATION On today’s battlefield medical providers will be required to manage their patients fluid resuscitation from point of wounding until their arrival at the FST or CSH. – CASEVAC/MEDEVAC assets may be delayed or mission may require patient hold on the battlefield or in the BAS for hours to days. Hypotensive resuscitation initially Maintenance protocols –I&O monitoring

3. HYPOTENSIVE RESUSCITATION IV access must be gained. The use of a single 18 gauge catheter is recommended. A heparin, saline lock-type access tubing, extension set, or 3 way stop-cock should be used unless the patient needs immediate resuscitation. Insure the IV site isn’t established distal to a significant wound.

4. HYPOTENSIVE RESUSCITATION Splint if the site is over a joint to prevent dislodgement during transport. If unable to start an IV consider starting a sternal Inter-Osseous line to provide fluids. A caveat-If you do this insure the skin is prepped well. Osteomyelitis in the manubrium is VERY BAD!!!

5. FLUID RESUSCITATION After initial resuscitation if CASEVAC/MEDEVAC is impossible or delayed for any reason; fluid maintenance must be recalculated based on the patients condition, supplies, and time available. Maintenance rate calculation when NPO: (Weight in Kg) + 40 = ml per hour of infusion rate.

6. FLUID RESUSCITATION End Points of resuscitation for controlled hemorrhage and dehydration: –Normal BP –Pulse –Urine output (0.5-1 ml/kg/hr) –Normal capillary refill –Good mentation

7. FLUID RESUSCITATION If patient can accept p.o fluids begin Oral Rehydration Salts (ORS), water, and “other fluids” as tolerated. Pre-packaged ORS are very prevalent “Downrange”, but patients for the most part, hate the taste and will require some encouragement. Gatorade though not quite as good has better compliance. ORS Recipe- 4 tsp sugar, ½-1 tsp salt, 1L water

8. BURN RESUSCITATION Adults: 2-4 cc LR x Kg body weight x % BSA burn. Children: 3-4 cc LR x kg body weight x % BSA burn.

9. BURN RESUSCITATION The infusion rate is regulated so that ½ the estimated volume will be administered in the first 8 hours post burn-the time when capillary permeability and intra-vascular volume loss are greatest. The remaining half of the estimated resuscitation volume should be administered over the subsequent 16 hours of the the first post burn day.

10. BURN RESUSCITATION The burn victim requires fluid maintenance in addition to the initial resuscitation!

11. IV DRIP RATE CALCULATION Macro Drip: Delivers rates greater than 100 ml/hr (Drip factor is 10 to 15 gtt/ml depending on equipment used. Drop Factor is printed on the box. Micro Drip: Delivers rates less than 100 ml/hr. Most commonly 60 gtt/ml.

12. CALCULATING FLOW RATE Flow Rate (ml/hr) = Total Infusion (Vol in ml) Hours of Infusion Time gtt factor x Flow Rate = Drop Rate 60 1 Example: Infuse 120ml/hr via 10gtt/ml Drop Factor

13. ALTERNATE METHOD FOR CALCULATION If drop factor is 10 gtt/ml, take ordered rate per hour and divide by 6. If drop factor is 15 gtt/ml, take ordered rate per hour and divide by 4. If drop factor is 20 gtt/ml, take ordered rate per hour and divide by 3. If drop factor is 60 gtt/ml, take ordered rate per hour and divider by 1.

14. MONITORING I & O Appropriate for patients that for whatever reason are in a hold status, and their condition requires close monitoring to maintain hemostasis. Anticipate, and bring graduated containers. Normally calculated q 8 hrs. Compare 24 hr totals over several days. Utilize resuscitation endpoints and UOP to help in making a CLINICAL DECISION –Increase or decrease the fluid maintenance based on your CLINICL DECISION

15. QUESTIONS???