fluids in trauma 2013

8/17/2019 Fluids in Trauma 2013

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FLUID RESUSCITATION IN

TRAUMA – AN UPDATE

Dr Sashi Kumar

Senior Staff Specialist

Emergency Medicine

The Canberra HospitalAUSTRALIA


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EMERGENCY DEPARTMENT

THE CANBERRA HOSPITAL


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FLUIDS IN TRAUMA –

A HISTORICAL UP DATE

1600 - WILLIAM HARVEY

CIRCULATION OF BLOOD

( AIR GOES IN AND OUTBLOOD GOES ROUND AND ROUND )

1800 – PHYSIOLOGICAL SALINE

1900 – MAJOR BLOOD TYPES


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HISTORY - CONTINUED• WORLD WAR 1 –CANNON ET AL 1918

• “IF THE PRESSURE IS RAISED WITHOUT A

SURGEON TO CHECK THE BLEEDING

BLOOD WILL BE LOST”

• VIETNAM WAR 1960S – LARGE VOLUME CRYSTALLOID RESUSCITATION –MADE SENSE

http://www.vietnam-war.0catch.com/vietnam_war_pics/vietnam_war_pics/wp17.jpghttp://www.vietnam-war.0catch.com/vietnam_war_pics/vietnam_war_pics/wp32.jpg


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Old Doctrine

- Give 2 litres of Ringers Lactate and watch the response !

- ATLS 7th edition early 1990 s

Large bore cannulae x 2(at least)

Level 1 Blood warmer

Continue to fill up !

Stay in the race !

Faster !Faster !Faster !

http://www.google.com.au/imgres?imgurl=http://www.trauma.org/images/image_library/21223463721July_125.jpg&imgrefurl=http://www.trauma.org/index.php/main/image/754/&usg=__I0_Gwh43Dt2UblB4ospkdGLZj6E=&h=1357&w=1783&sz=224&hl=en&start=50&zoom=1&tbnid=A0mjvPzEOTdkBM:&tbnh=114&tbnw=150&ei=fWckUer9BYf-lAWWkIHIBg&prev=/search%3Fq%3DTRAUMA%26start%3D40%26hl%3Den%26sa%3DN%26rls%3Dcom.microsoft:en-au%26biw%3D2276%26bih%3D1113%26ie%3DUTF-8%26tbm%3Disch&itbs=1&sa=X&ved=0CDwQrQMwCTgo


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Pre Hospital Phase

• Houston Texas

• NEJM OCT 1994

• 598 patients

• SBP


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PRE HOSPITAL CARE –

CRITICAL GOALS

• 1 . STOP THE EXTERNAL BLEEDING

• 2 . RAPID TRANSPORT

•3 . RESUSCITATE TO MAINTAINMENTAL STATUS AND PERIPHERAL

PULSES

http://esa.act.gov.au/community-information/calling-an-ambulance/


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PRE HOSPITAL CARE• A PROSPECTIVE MULTICENTRE CANADIAN STUDY IN 2003

ANNALS OF SURGERY• 9405 PATIENTS

• INCREASED MORTALITY WITH EVERY ATLS INTERVENTION

• SEAMON ET AL – RETROSPECTIVE STUDY J TRAUMA 2007

• 180 PENETRATING TRAUMA REQUIRING ED THORACOTOMY

•PRE HOSPITAL PROCEDURES

– INDEPENDENT PREDICTOROF BAD OUTCOME

• VASCULAR ACCESS NOT ESSENTIAL

• MINIMAL FLUIDS IF PULSE PRESENT


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FLUIDS - How much of what ?

• How much ?

• How fast ?

• What fluid ?

• For How long ?

What is stable?

STABLE IS A

STATE OF MIND !


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Permissive Hypotension

• Do not drown your patients !

• Accept Lower BP

• Radial pulse –enough

• Do the ATLS/CTLS dance and

stop the bleed ing !


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LACTATED RINGER SOLUTION• CREATED BY HARTMANN IN 1930S

• METABOLISED IN LIVER TO PYRUVATE OR

CO2 AND H2O

• RELEASE OF HYDROXIDE WHICH IS

CONVERTED TO BICARBONATE• OFFERS PHYSIOLOGICAL BUFFER TO

ACIDOSIS

http://www.google.com.au/imgres?imgurl=http://www.medshop.co.nz/image/cache/data/file_33_11-500x500.jpg&imgrefurl=http://www.medshop.co.nz/lactated-ringers-1000-mls&usg=__HiiUv0zGMNsu8JyVb3GNEn6BXQs=&h=500&w=500&sz=115&hl=en&start=11&zoom=1&tbnid=D0EuXd5C0T0vYM:&tbnh=130&tbnw=130&ei=HjokUdeIPMiAkQXLuoCAAw&prev=/search%3Fq%3Dlactated%2Bringer%2527s%26hl%3Den%26sa%3DN%26rls%3Dcom.microsoft:en-au%26biw%3D2276%26bih%3D1113%26ie%3DUTF-8%26tbm%3Disch&itbs=1&sa=X&ved=0CD4QrQMwCg


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COLLOIDS

• SALINE VS ALBUMIN FLUID EVALUATION( SAFE ) STUDY NEJM 2004

• 7000 CRITICALLY ILL ICU PATIENTS

• 4 % ALBUMIN VS N SALINE

• NO BENEFICIAL EFFECTS ONMORTALITY MORBIDITY OR LOS IN ICU

• COCHRANE REVIEW IN 2007 -

•NO REDUCTION IN DEATH / EXPENSIVE

NORMAL SALINE

http://www.google.com.au/imgres?imgurl=http://www.transfusion.com.au/sites/default/files/Albumex_4_20g-small.jpg&imgrefurl=http://www.transfusion.com.au/blood_products/fractionated_plasma/albumin&usg=__AxFmphYMVo82OlLNZO6wE07br0c=&h=328&w=248&sz=22&hl=en&start=1&zoom=1&tbnid=zMEa2l9o6ThhSM:&tbnh=118&tbnw=89&ei=ez4kUYiYEsebkgW96oDIDA&prev=/search%3Fq%3D4%2B%2525%2BALBUMIN%26hl%3Den%26sa%3DX%26rls%3Dcom.microsoft:en-au%26biw%3D2276%26bih%3D1113%26ie%3DUTF-8%26tbm%3Disch&itbs=1&sa=X&ved=0CCoQrQMwAA


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NORMAL SALINE• CAUSES HYPERCHLOREMIC ACIDOSIS

WHEN GIVEN IN LARGE VOLUMES

• UNCONTROLLED HAEMORRHAGICSHOCK IN PIGS – TODD ET AL 2007

• HIGHER VOLUME REQUIRED / MORE

ACIDOTIC / LOWER FIBRINOGEN ANDWORSE COAGULOPATHY


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RESUSCITATION INJURY

CAPILLARY PERMEABILITY INCREASES

CELLULAR SWELLING AND DYSFUNCTION

FLUID OVERLOAD AND OEDEMA BEGETS FURTHER

FLUIDS AND OEDEMAVIETNAM WAR – ACUTE LUNG INJURY DA NANG LUNG

ADULT RESPIRATORY DISTRESS SYNDROME ( ARDS )

ABDOMINAL COMPARTMENT SYNDROME

http://www.google.com.au/imgres?imgurl=http://upload.wikimedia.org/wikipedia/en/thumb/9/94/7_RAR_Vietnam_(AWM_EKN-67-0130-VN).jpg/300px-7_RAR_Vietnam_(AWM_EKN-67-0130-VN).jpg&imgrefurl=http://en.wikipedia.org/wiki/Military_history_of_Australia_during_the_Vietnam_War&usg=__bFs6W3xgMQHBw3uJ7OeB7uW9Rzs=&h=249&w=300&sz=28&hl=en&start=8&zoom=1&tbnid=pavrtsVJoMIqlM:&tbnh=96&tbnw=116&ei=VXAkUbSsL8OTkQW74IGYCw&prev=/search%3Fq%3Dvietnam%2Bwar%26hl%3Den%26sa%3DX%26rls%3Dcom.microsoft:en-au%26biw%3D2276%26bih%3D1113%26ie%3DUTF-8%26tbm%3Disch&itbs=1&sa=X&ved=0CDgQrQMwBwhttp://www.vietnam-war.0catch.com/vietnam_war_pics/vietnam_war_pics/wp31.jpghttp://www.vietnam-war.0catch.com/vietnam_war_pics/vietnam_war_pics/wp6.jpg


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HYPERTONIC SALINE

SINCE 1980SVOLUME EXPANSION AND RESTORATION OF

T CELL FUNCTION IN ANIMAL STUDY – 1997

COCHRANE REVIEW 2004

NO DIFFERENCE IN MORTALITY BETWEENHYPERTONIC AND ISOTONIC SALINE

COOPER ET AL – JAMA 2004 PROSPECTIVERANDOMISED STUDY

RCT 229 PATIENTS WITH TBI 250 MLS 7.5%SALINEVS RINGERS

NO DIFFERENCE IN MORTALITY OR GLASGOWOUTCOME SCALE EXTENDED ( GOSE )

http://www.google.com.au/imgres?imgurl=http://www.valleyvet.com/swatches/308RX_L_vvs_000.jpg&imgrefurl=http://www.valleyvet.com/ct_detail.html%3Fpgguid%3D30e079fb-7b6a-11d5-a192-00b0d0204ae5&usg=__RYWNI2MU4Om5-vaAtemBQPWVrts=&h=2114&w=778&sz=681&hl=en&start=4&zoom=1&tbnid=5J5pPBnWBNuRrM:&tbnh=150&tbnw=55&ei=rkckUdaDKoWikgXh6oDoDw&prev=/search%3Fq%3Dhypertonic%2Bsaline%26hl%3Den%26sa%3DX%26rls%3Dcom.microsoft:en-au%26biw%3D2276%26bih%3D1113%26ie%3DUTF-8%26tbm%3Disch&itbs=1&sa=X&ved=0CDAQrQMwAw


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GIVE BLOOD EARLY

• Do not fill up with fluids

• Do not cheat

• Emphasis on early blood

and products

•Stop the bleed ing


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BLOOD substitutes

• Ideal fluid

• safe

• Carries O2

• Cheap

• Easy to store

•More research needed

• New developments in Fluid resuscitation - Hasan B Alam

Surgical clinics of N America Feb 2007


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SUMMARY

PRE HOSPITAL PHASE

• RAPID TRANSPORT

• AVOID TIME CONSUMING ATLS

PROCEDURES - LEVEL II• IV ACCESS NOT MANDATORY

• IV FLUIDS TO KEEP VEIN OPEN

• RESUSCITATE TO ADEQUATE MENTALSTATUS AND PERIPHERAL PULSES


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SUMMARY – IN ED• CHOICE OF FLUID

- NO EFFECT ON OUTCOME LEVEL I

• LACTATED RINGER HAS

THEORETICAL ADVANTAGES LEVEL III

• AVOID LARGE VOLUME CRYSTALLOID

RESUSCITATION LEVEL III

•UNCONTROLLED HAEMORRHAGE ANDNO TBI SBP 70 – 90 LEVEL III


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SUMMARY –IN ED

•INITIATE MASSIVE TRANSFUSIONPROTOCOL IN SELECTED PATIENTS

• USE FIXED RATIOS OF BLOOD AND BLOOD

PRODUCTS LEVEL II

• GIVE TRANEXAMIC ACID TO ALL PATIENTSWITH UNCONTROLLED HAEMORRHAGE

AND REQUIRING TRANSFUSION LEVEL I


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CONCLUSION

• DEBATE CONTINUES ON IDEAL FLUID IN TRAUMA

RESUSCITATION

• NO DIFFERENCE BETWEEN COLLOID AND

CRYSTALLOID

• AVOID LARGE VOLUMES OF N SALINE

• USE BLOOD AND BLOOD PRODUCTS EARLY

• STOP THE BLEEDING !


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REMEMBER

“NOT EVERYTHING THAT COUNTS CAN

BE COUNTED AND NOT EVERYTHING

THAT CAN BE COUNTED COUNTS’’

(ALBERT EINSTEIN )


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25/25Thank You !

fluids in trauma 2013

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