- See:
- Transfusion Menu / Blood Product Menu
- Subclavian Vein Catheterization and Internal Jugular Approach
- Assessment of perfusion: damage control orthopaedics
- normal blood pressure (systolic), heart rate, urine output (
30 mL/hr);
- labs: base deficit, bicarbonate, and lactate
- Initial Fluid Resusitation in the Adult Trauma Patient:
- initially the adult trauma pt should rapidly be given 2 liters of a balanced salt solution w/ observation of response;
- if there is no improvement in vital functions, than an additional fluid load should be instituted with the addition of pRBC;
- 1:1:1 Tranfusion of pRBC, FFP and platelets
- Effect of a fixed-ratio (1:1:1) transfusion protocol versus laboratory-results-guided transfusion in patients with severe trauma: a randomized feasibility trial.
- Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) Trial: design, rationale and implementation
- Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial.
- misc:
- use of naloxonne, vasopressors, diuretics, and bicarbonate is rarely indicated in initial resuscitation of trauma patient;
- caution is observed in allowing water intake, as dangerous water intoxication may occur with intense thirst stimulus;
- many trauma pts will have elevated levels of antidiuretic hormone from trauma, whether or not shock has occurred;
- serial hematocrit:
- in early shock, tachnypnea leads to respiratory alkalosis followed by metabolic acidosis due to poor tissue perfusion and will
reverse w/ adequate volume has been restored;
- classification of hemorrhage:
- 70 kg male holds approximately 5 liters of blood or equivalent of 25 units pRBC;
- class I:
- loss of up to 15% of the blood volume or 4 units pRBC loss;
- normally does not cause a change in blood volume or pressure;
- w/ supine position, as much as 1000 ml of blood may be maintained w/o causing a significant increase in peripheral pulse;
- class II:
- loss of 15% to 30% of blood volume or 4-8 pRBC loss;
- normally results in increased pulse but no change in systolic blood pressure;
- these patients can most often be resuscitated with a crystalloid, but some may require blood transfusion (pRBC);
- class III:
- loss of 30% to 40% of circulating blood volume which is about 2 liters;
- this results in tachycardia and loss of systolicblood pressure and decreased mental status;
- patients are given 2 liters of saline over 20 min or less while blood is prepared;
- blood pressure should be maintained with crystalloid until blood is ready;
- w/ recurrent hypotension, give two more liters of crystalloid, and type-specific or non–cross-matched
universal-donor (i.e., group O neg) blood is given;
- class IV:
- loss of more than 40% of blood volume;
- marked tachycardia, significantly decreased systolic blood pressure, cold and pale skin, severely decreased mental status,
negligible urine output;
- references:
- Evolution of a multidisciplinary clinical pathway for the management of unstable patients with pelvic fractures.
- Fresh frozen plasma should be given earlier to patients requiring massive transfusion.
-
A high fresh frozen plasma: packed red blood cell transfusion ratio decreases mortality in all massively transfused trauma patients regardless of admission international normalized ratio.
- Effect of high product ratio massive transfusion on mortality in blunt and penetrating trauma patients
- Resuscitation Strategies in Trauma
- Types of Fluids:
- crystalloid:
- 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;
- generally, two to four times as much crystalloid as 5% albumin or 6% hetastarch is required to achieve the
same physiologic endpoints;
- colloids:
- 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;
- plasmanate (plasma protein fraction)
- is a 5% protein solution containing both albumin and alpha and beta globulins;
- paradoxical hypotension has been noted during the infusion of plasma protein fraction and has been attributed to acetate,
present as a buffer, or the presence of Hageman factor fragments
- Resusitation for Infants and Children:
- LR bolus 20 ml/kg x 2-3 as required
- then pRBC 10 ml/kg x 1
- continue fluid administration until CVP > 5 mm Hg;
- Daily Fluid Requirements:
- minimum requirements for fluid balance can be estimated from the sum of the urine output necessary to excrete the daily solute
load (500 ml/ day) plus insensible (evaporative) water losses from the skin and resp tract (500-1000 ml/day) minus the amount
of water produced from endo-genous metabolism (300 ml/day);
- the kidney must excrete about 600 mOsm of solute/day (primarily Na, K, and urea) in the normal adult;
- since the maximum urinary concentrating ability is 1200 mOsm/kg, the minimum urine output required to excrete the osmotic
load is 500 ml/day;
- it is customary to administer 2000-3000 ml of water daily to produce about 1000-1500 ml/day urine output, since there is
no advantage gained by minimizing urine output;
Damage Control Resusitation
Mortality after Fluid Bolus in African Children with Severe Infection