1. FLUID RESUSCITATION CURRENT THINKING Dr Sean R Santos CGH

2. Objectives Define Shock Consider methods for recognising the shocked casualty Discuss pre-hospital management In-hospital Management Future Developments

3. Shock Failure to achieve adequate perfusion and oxygenation of the tissues

4. Types of shock Hypovolaemic Cardiogenic Inc Tamponade/Tension Septic Neurogenic Anaphylactic

5. Hypovolaemic Shock

6. Class I 750 mL (15%) ● Slightly anxious ● Normal blood pressure ● Heart rate < 100 / min ● Respirations 14-20 / min ● Urinary output 30 mL / hour ● Warm skin, Normal Cap Refill

7. Class II 750-1500 mL (15-30%) ● Anxious ● Normal blood pressure ● Heart rate > 100 / min ● Decreased pulse pressure ● Respirations 20-30 / min ● Urinary output 20-30 mL / hour ● Pale, Cool, Cap Refill Delayed

8. Class III 1500-2000 mL (30-40%) ● Confused, anxious ● Decreased blood pressure ● Heart rate > 120 / min ● Decreased pulse pressure ● Respirations 30-40 / min ● Urinary output 5-15 mL / hour ● V. Pale, Sweaty, Cap refill V Delayed

9. Class IV >2000 mL (>40%) ● Confused, lethargic ● Hypotension ● Heart rate > 140 / min ● Decreased pulse pressure ● Respirations >35 / min ● Urinary output negligible

10. Pulses Radial70-80 mmHg Femoral60-70 mmHg Carotid≤60 mmHg

11. Early Indicators Resp Rate Colour Cap refill Mental State

12. Management Historical New Strategies

13. Historical Two Large Bore Cannulae Two Litres Of Fluid Continue Replacement until HR Normal Control Bleeding

14. New Strategies Preservation Bleeding Control Fluid Management

15. Preservation Rapid Transfer Surgical/Radiological Management of Bleeding Permissive Hypotension Immobilisation of Fractures Gentle Handling to preserve Clot

16. Preservation Visible Haemorrhage Direct Pressure Indirect Pressure Tourniquet

18. Tourniquets Proximal Adequate Pressure Communication, Orange for Visibility Aim for max 2 hours Adequate facilities on release

19. Clot Promotion Quick Clot Dressings Fibrin Sealants

20. Pelvic Slings

21. Fluid Management Isotonic Fluids Colloids Hypertonic Fluids

22. Colloids vs. Crystalloids Stay in circulation Plasma Expand May disrupt Clotting Direct and Dilutional Anaphylaxis ? Cellular acidosis Lesser Volume All fluid compartments No direct effect on Clotting ? Cellular function better preserved Greater volume c. X3

23. Not What How Much

24. PulseNothing No pulse250ml Bolus ? Response ? Repeat UnconsciousMeasure BP ≤100 mmHg 250ml ≥100 mmHg Nothing

25. Route Big IV Cannula Intra Osseous

26. Current/Future Developments Hypertonic Solutions Damage Control Resuscitation Damage Control Surgery

27. Hypertonic Solutions 5, 7.5, 10%Saline +/- Colloid Rapid, Sustained BP increase Small Volume Diuresis ↓ Intracranial Pressure

28. Damage Control Resuscitation Damage Control Surgery

29. Damage Control Resuscitation Lethal TriadHypothermia Acidosis Coagulopathy

30. Damage Control Resuscitation Permissive Hypotension Haemostatic Resuscitation Damage Control Surgery

31. Haemostatic Resuscitation Packed Cell1unit FFP1unit Platelets1 bag/4-6 Calcium, Tranexamic Acid, Factor VIIa

32. Damage Control Surgery

33. ?

34. Conclusions Recognition Preservation Small Volume Resuscitation Control Of Bleeding