- See:
-
Transfusion Menu /
Blood Product Menu:
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Subclavian Vein Catheterization and
Internal Jugular Approach
- 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;
- the use of naloxonne, vasopressors, diuretics, and bicarbonate is rarely indicated in the initial resuscitation of the trauma patient;
- 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;
- as long as the pt is in the supine position, as much as 1000 ml of blood may be maintained w/o causing a significant increase in peripheral pulse;
- many trauma pts will have elevated levels of antidiuretic hormone from trauma, whether or not shock has occurred;
- caution must be observed in allowing water intake, as dangerous water intoxication may occur with the intense thirst stimulus;
- serial
hematocrit:
-
classification of hemorrhage:
- 70 kg male holds approximately 5 liters of blood or equivalent of 25 units pRBC;
-
class I:
- loss of upto 15% of the blood volume or 4 units pRBC loss;
- normally does not cause a change in blood volume or pressure;
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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);
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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 (ie, group O neg)
blood is given;
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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;
- consider 2-3 units of
FFP and a six pack of
platelets for every 5 liter of volume replacement;
- references:
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Evolution of a multidisciplinary clinical pathway for the management of unstable patients with pelvic fractures.
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Fresh frozen plasma should be given earlier to patients requiring massive transfusion.
- Assessment of Resusitation:
- normal blood pressure (systolic), heart rate, urine output (
30 mL/hr);
- labs:
base deficit, bicarbonate, and lactate
- 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;
- 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;
- References:
Damage Control Resusitation
Hemoglobin drops within minutes of injuries and predicts need for an intervention to stop hemorrhage.
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