Fluid Management in the Trauma Patient

- 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

    Hemoglobin drops within minutes of injuries and predicts need for an intervention to stop hemorrhage.

    Mortality after Fluid Bolus in African Children with Severe Infection

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Thursday, November 2, 2017 4:39 am