fluid resuscitation current thinking dr sean r santos cgh
Post on 23-Dec-2015
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FLUID RESUSCITATION
CURRENT THINKING
Dr Sean R Santos
CGH
Objectives
• Define Shock• Consider methods for recognising the
shocked casualty• Discuss pre-hospital management• In-hospital Management• Future Developments
Shock
Failure to achieve adequate perfusion and oxygenation of the
tissues
Types of shock
• Hypovolaemic
• Cardiogenic Inc Tamponade/Tension
• Septic
• Neurogenic
• Anaphylactic
Hypovolaemic Shock
Class I 750 mL (15%)
● Slightly anxious
● Normal blood pressure
● Heart rate < 100 / min
● Respirations 14-20 / min
● Urinary output 30 mL / hour
● Warm skin, Normal Cap Refill
Class II 750-1500 mL (15-30%)
● Anxious
● Normal blood pressure
● Heart rate > 100 / min
● Decreased pulse pressure
● Respirations 20-30 / min
● Urinary output 20-30 mL / hour
● Pale, Cool, Cap Refill Delayed
Class III 1500-2000 mL (30-40%)
● Confused, anxious
● Decreased blood pressure
● Heart rate > 120 / min
● Decreased pulse pressure
● Respirations 30-40 / min
● Urinary output 5-15 mL / hour
● V. Pale, Sweaty, Cap refill V Delayed
Class IV >2000 mL (>40%)
● Confused, lethargic
● Hypotension
● Heart rate > 140 / min
● Decreased pulse pressure
● Respirations >35 / min
● Urinary output negligible
Pulses
• Radial 70-80 mmHg
• Femoral 60-70 mmHg
• Carotid ≤60 mmHg
Early Indicators
• Resp Rate
• Colour
• Cap refill
• Mental State
Management
Historical
New Strategies
Historical
• Two Large Bore Cannulae
• Two Litres Of Fluid
• Continue Replacement until HR Normal
• Control Bleeding
New Strategies
Preservation
Bleeding Control
Fluid Management
Preservation
• Rapid Transfer
• Surgical/Radiological Management of Bleeding
• Permissive Hypotension
• Immobilisation of Fractures
• Gentle Handling to preserve Clot
PreservationVisible Haemorrhage
• Direct Pressure
• Indirect Pressure
• Tourniquet
Tourniquet
Tourniquets
• Proximal
• Adequate Pressure
• Communication, Orange for Visibility
• Aim for max 2 hours
• Adequate facilities on release
Clot Promotion
• Quick Clot• Dressings• Fibrin Sealants
Pelvic Slings
Fluid Management
• Isotonic Fluids
• Colloids
• Hypertonic Fluids
Colloids vs. Crystalloids
• Stay in circulation• Plasma Expand• May disrupt Clotting
Direct and Dilutional• Anaphylaxis• ? Cellular acidosis
• Lesser Volume
• All fluid compartments
• No direct effect on Clotting
• ? Cellular function better preserved
• Greater volume c. X3
Not What
How Much
How Much
• Pulse Nothing
• No pulse 250ml Bolus ? Response ? Repeat
• Unconscious Measure BP ≤100 mmHg 250ml ≥100 mmHg Nothing
Route
• Big IV Cannula
• Intra Osseous
Current/Future Developments
• Hypertonic Solutions
• Damage Control Resuscitation
• Damage Control Surgery
Hypertonic Solutions
• 5, 7.5, 10%Saline• +/- Colloid• Rapid, Sustained BP
increase• Small Volume• Diuresis• ↓ Intracranial
Pressure
Damage Control Resuscitation
Damage Control Surgery
Damage Control Resuscitation
• Lethal Triad Hypothermia
Acidosis
Coagulopathy
Damage Control Resuscitation
• Permissive Hypotension
• Haemostatic Resuscitation
• Damage Control Surgery
Haemostatic Resuscitation
• Packed Cell 1unit
• FFP 1unit
• Platelets 1 bag/4-6
• Calcium, Tranexamic Acid, Factor VIIa
Damage Control Surgery
?
Conclusions
Recognition
Preservation
Small Volume Resuscitation
Control Of Bleeding
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