protocol of trauma resuscitation
TRANSCRIPT
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Transfer Protocol in I CU
Hosam M Atef
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Airway
Patients with (or at risk from) airway
compromise should be intubated prior to
transfer
The tracheal tube should be secured and
confirmed in correct position
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BreathingPatient adequately sedated if ventilated
Ventilation established (and stable) on transport
ventilator
Adequate gas exchange on transport ventilator
confirmed by arterial blood gas analysis
Adequate oxygen supply on transfer vehicle
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Circulation
Adequate intravenous access
Circulating volume optimized
Hemodynamically stable
All lines are patent and secured
Any active bleeding controlled
Long bone/pelvic fractures stabilized
ECG and blood pressure monitored
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C. Spine
Adequate spinal immobilization (if indicated)
Disability
No active seizures
Initial treatments for raised intracranial pressure (if
indicated)
Life-threatening electrolyte disturbances corrected
Blood glucose >70 mg/dl
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Exposure
Patient adequately covered to prevent heat
loss
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Trauma Protocol
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Resuscitation protocol in traumatic hemorrhagic shock General principle:
Traumatic death is the main cause of life years lost worldwide.
Hemorrhage is responsible for almost 50% of deaths in the first
24 h after trauma.
The optimal resuscitative strategy is controversial:
Choice of fluid
Target of hemodynamic goals for hemorrhage control
The optimal prevention of traumatic coagulopathy are questions.
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Fluid resuscitation I. Type of fluid
Lactated Ringer’s solution is recommended
as first-line resuscitation fluid in trauma
patients
Albumin should be avoided in patients with
TBI
In patients with TBI, isotonic saline should be
preferred over hypotonic fluids because it can
reduce the risk of cerebral edema.
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II. Endpoints of resuscitation
Three different target systolic blood pressure values can
be considered for three different traumatic conditions
before controlling source of hemorrhage:
60–70 mmHg for penetrating trauma
80–90 mmHg for blunt trauma without TBI
100–110 mmHg for blunt trauma with TBI
Lactate ≥ 2 mmol/L and base deficits ≥ -5 mEq/L have
been demonstrated useful to stratify patients who need a
larger amount of fluid after the initial resuscitation.
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III. Vasopressor
Early use of norepinephrine could limit fluid
resuscitation and hemodilution.
The dose of norepinephrine should be titrated
until we reach the target systolic blood
pressure as indicated above
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IV. Transfusion and prevention of acute coagulopathy of trauma
The correction and prevention of traumatic
coagulopathy have become central goals of early
resuscitative management of hemorrhagic shock.
a) Red blood cells
In patients without TBI: Target haemoglobin level
(7-9 g/dL)
In patients with severe TBI (GCS ≤ 8): Target
haemoglobin level ≥ 10 g/dL
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a) Fresh Frozen Plasma (FFP)
In all patients FFP should be considered
when PT or PTT ≥ 1.5 times normal value
The initial recommended dose of FFP is 10 to
15 ml/kg
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b) Platelet
In patients without TBI: Platelet transfusion
is recommended when platelet count ≤
50.000/L
In patients with TBI: Platelet transfusion is
recommended when platelet count ≤
100.000/L
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c) Fibrinogen
In all patients, fibrinogen level should be maintained ≥ 150-
200 mg/dL
If The use of FFP failed to rapidly correct the
hypofibrinogenemia
Resuscitation with 10 to 15 mL/kg of FFP only increased the
fibrinogen plasma level to 40 mg/dL
More than 30 mL.kg of FPP should be necessary to increase
the fibrinogen plasma level to 100 mg/dL
Ten single bags of cryoprecipitate derived from whole blood
are needed to raise the plasma fibrinogen level by 100 mg/dL
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d) Adjuvant Therapy
I. Tranxemic acid: routine administration of tranexamic
acid (loading dose of 1 g over 10 min, then infusion of 1g
over 8 hr) in patients with hemorrhagic shock was
associated with a decreased mortality rate.
II. Factor VIIa: No clear recommendation to use activate
factor VII and the use of this factor should be discussed on
a case-by-case basis.
III. Ionized calcium level should be maintained between
1.1-1.3 mmol/L
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