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

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

3. 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.

4. 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

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

6. 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

7. 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

9. 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

10. 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

11. * 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

12. 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. 

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

14. 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.

17. 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

18. 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"

20. 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

21. 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

22. 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 .

23. Others
Albumin
Hypertonic saline solutions
Hemoglobin solutions

24. 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. 

25. 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.

26. 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.

27. 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

28. 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

29. 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.

30. 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

31. 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

32. 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

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

34. May Be NOT

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

36. 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).

37. 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

38. 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

39. 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

41. Regardless of the resuscitation formula or strategy used, the first 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.

42. 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.

43. Question?

44. Thank You