Fluid and blood resuscitation

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Fluid and blood resuscitation
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intro

• Hemorrhage
• Thorax
• Abdomen
• Gynecologic
• orthopaedic
• Burns
• GI disorders
• Environmental losses

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Fluid rescusitation

• Goals
• to restore intravascular volume sufficient for
  critical organ perfusion
• to maintain oxygen-carrying capacity for adequate
  cellular oxygen delivery
• to correct derangements in coagulation.
• Aggressive resuscitation may actually accelerate
  RBC loss, so permissive hypotension may be used
  in initial phase.
• Not recommended by ATLS

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Pathophys


Table 26-2 Most Common Causes of Coagulopathy in Trauma
Massive hemorrhage
Hypothermia
Consumption of clotting factors
Consumption of platelets
Dilution of clotting factors and platelets
Trauma-induced fibrinolysis
Massive blood transfusions
Hypocalcemia
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pathophys

• Hemorrage -gt endothelial damage -gt clotting
  cascade and vasoconstrictive mediators
• Lethal Triad
• Acidosis
• Hypothermia
• coagulopathy

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Clinical features
Hemorrhage Class Blood Loss Clinical Response
Class I     15 (750 mL) Minimal or no tachycardia, no change in blood pressure in healthy patients
Class II 1530 (7501500 mL) Tachycardia and narrowed pulse pressure, mild to moderate hypotension compensatory peripheral vasoconstriction, possibly mild mental status changes
Class III 3040 (15002000 mL) Worsening hypotension, tachycardia, peripheral hypoperfusion, and mental status changes
Class IV gt40 (gt2000 mL)
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Pearls

• Elderly patients may not develop a tachycardic
  response to blood loss due to underlying heart
  disease or medications such as beta-adrenergic
  blockers.

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pearls

• Bradycardia or lack of tachycardia may occur in
  about 30 of patients with intra-abdominal
  hemorrhage from increased vagal tone in response
  to hemoperitoneum

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pearls

• In a pregnant trauma patient, compression of the
  inferior vena cava by the gravid uterus can
  decrease central venous return and worsen
  hypotension and tachycardia in the setting of
  less severe hemorrhage.

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treatment
IV Access Gravity (80 cm height) Pressure (300 mm Hg)
18 gauge peripheral IV 5060 mL/min 120180 mL/min
16 gauge peripheral IV 90125 mL/min 200250 mL/min
14 gauge peripheral IV 125160 mL/min 250300 mL/min
8.5F central venous introducer 200 mL/min 400500 mL/min

• ACBCD
• Control hemorrhage
• IV access

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Isotonic crystalloids

• NS and LR are hypo-oncotic, so they shift into
  extravascular space.
• physiologic basis for the 31 ratio for isotonic
  crystalloid volume replacement
• for every amount of blood lost, three times that
  amount of isotonic crystalloid is required to
  store intravascular volume because, at best,
  about 30 of the infused fluid stays
  intravascular.

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Blood transfusion

• RBCs most common
• Indicated if no or minimal response to 2-3 liters
  of fluid administration
• Hgb lt 6 transfuse
• Hgb gt 10 hold transfusion
• Hgb gt6 but lt10 clinical judgement

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• Coloids
• Higher oncotic pressure
• No mortality benefit as compared to crystalloids
• Much more expensive

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resources

• Tintinalli, Ch. 26