Life Support in Haemorrhage

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Life Support in Haemorrhage and Fluid Loss H.Gee
MD, FRCOG
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TRIAGE

• Priority 1
• Requires emergency treatment and resuscitation
  soon or she will die.
• Priority 2
• Care may be delayed a few hours.
• Priority 3
• Condition permits significant delay.

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Life support in haemorrhage and fluid loss

• Recognise circulatory collapse (SHOCK) and treat
• ABC
• Call for help.
• CAUSES
• Haemorrhage
• Sepsis.
• Life-threatening needs immediate and intensive
  treatment - PRIORITY 1
• Inadequate perfusion of organs and cells with
  oxygenated blood.

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Recognising circulatory collapse (SHOCK)
Main signs and symptoms Other signs and symptoms
Pulse weak and fast (gt110 beats/minute) Pallor
BP low (systolic lt90 mmHg) (late sign) Sweatiness or cold and clammy skin
Rapid breathing
Anxious, confused
Unconscious
Fetal distress
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Classification of circulatory volume loss
NB A pregnant woman has a circulation volume of
about 100 ml/kg (for a woman of 60kg this is 6
litres).
Class Circulating volume lost Signs
1 15 or less (not much more than 700ml) You may notice only a mild rise in pulse rate If the woman is otherwise healthy and if not anaemic she will not require a blood transfusion
2 15-30 (over 1.5L) Symptoms will include rising pulse rate and rising breathing frequency Use crystalloids to replace fluid loss
3 30-40 (over 2L) It is only at this stage that the blood pressure falls Remember a drop in BP is a later sign of hypovolaemia Patient will need a blood transfusion in addition to crystalloids
4 gt40 This is immediately life threatening Blood transfusion is required immediately
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Action

• Call for help
• Position woman on her left side with legs higher
  than her chest
• Remember in the pregnant woman any shock is
  made worse by aorta-caval compression
• Insert at least one IV line give fluids at
  rapid rate
• Cover patient to keep warm
• Assess condition of mother and child
• If at Health Centre, once initial treatment
  commenced, refer to hospital
• Management of haemorrhage or sepsis.

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Fluid Management

• Insert IV line and give fluids
• Clean womans skin with spirit at site for IV
  line
• Insert an IV line using 16-18 gauge needle
• Infuse Ringer lactate or normal saline.
• Give fluids at rapid rate if systolic blood
  pressure (BP) less than 90 mmHg, pulse faster
  than 110 beats/minute or heavy vaginal bleeding
• Infuse 1L in 15-20 minutes (as rapid as you can)
• After that, infuse 1L in 30 minutes at 30
  ml/minute
• Repeat if necessary.

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Fluid Management ...continued...

• Monitor every 15 minutes for
• Pulse and BP
• Shortness of breath or puffiness.
• Reduce the infusion rate
• To 3 ml/minute (1L in 6-8 hours) when pulse slows
  to less than 100 beats/minute, systolic BP
  increases to 100 mmHg or higher
• To 0.5 ml/minute(1L in 18-24 hours) if breathing
  difficulty or puffiness develops.

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Reassessment and further management

• Reassess the womans response to IV fluids within
  30 minutes for signs of improvement
• Stabilising pulse (90 beats/minute or less)
• Increasing systolic blood pressure (100 mmHg or
  more
• Improving mental status (less confusion or
  anxiety)
• Increasing urine output (30 ml/hour or more).
• If condition improves
• Adjust rate of IV infusion to 1L in 6 hours
• Continue to manage underlying cause of
  circulatory collapse.

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CAUTIONS

• Give fluids at moderate rate (1L in 2-3 hours)
  in
• Severe abdominal pain
• Obstructed labour
• Fever and dehydration.
• Give fluids at slow rate (1L in 6-8 hours) in
• Severe anaemia
• Pre-eclampsia
• Eclampsia.
• ALWAYS
• Monitor urine output insert catheter if
  available
• Use fluid balance sheet to record time and amount
  of fluids.

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No IV access

• Oral rehydration solution if able to drink 500
  ml/hour or by NG tube
• Venous cut-down.

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Procedure for venous cut-down
The saphenous vein is about one finger anterior
and superior to the medial malleolus (on inner
side of the ankle).
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Coagulation Defects

• Abruption
• Large Transfusions

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Transfusion gt 4 Units(Stored Blood)

• Consider
• Platelets
• Fresh Frozen Plasma (clotting factors)
• Cryo-precipitate (fibrinogen)
• Calcium Gluconate