Trauma basics 3
Remember - Hypoxia and hypotension kill head-injured patients.
Circulation
- 2 large bore intravenous cannulae (16 gauge or larger).
- If percutaneous peripheral IV access cannot be achieved proceed to venous cutdown (long saphenous vein above medial malleolus or antecubital fossa) or use a femoral or central venous line.
- Try to avoid using veins in the lower limb unless absolutely necessary (risk of DVT) and certainly not if there is pelvic or abdominal trauma involving large venous plexuses.
Fluid resuscitation
- Connect dual IV pump sets or use pressure infusion bags. Blood filters are not necessary in the Emergency Department during emergency transfusion.
- Commence fluid resuscitation with Normal Saline or Hartmanns Solution. Use blood if the patient has lost a lot of blood (O negative for females of childbearing age, otherwise O positive can be used).
- Colloids are not indicated in resuscitation.
- If the patient has penetrating trauma and early surgery is possible, minimal fluid resuscitation is indicated.
- Hypertonic saline is undergoing trials as a resuscitation agent. It has many potential benefits, including small volume and potential neuroprotective effects.
- In the future, synthetic blood substitutes may have a role in resuscitation.
In young fit patients, the pulse rate is a better indicator of blood loss than blood pressure.
Crystalloid vs. colloid in resuscitation
Delayed fluid resuscitation in penetrating trauma
Aim of fluid resuscitation
In general aim for a systolic BP of 100 mmHg and a pulse rate less than 100 bpm but do not overtransfuse. Allow for effects of anxiety and pain on these parameters.
Urine output is also a useful indicator of the adequacy of fluid resuscitation (aim for greater than 0.5 -l ml/kg/hour).
After 2 litres of crystalloid, if further fluid is required, blood should be used.
Paediatric trauma
- Children maintain BP until relatively late and then decompensate quickly.
- Initial fluid bolus should be 20ml/kg. If still shocked, repeat 20 ml/kg fluid.
Pregnancy
- In the third trimester shock may be difficult to diagnose. Normal BP may be around 100 mmHg and resting pulse rate may be normally around 100.
- Remember that trauma to the uterus may result in concealed bleeding and that fetal distress is often undetectable without cardiotocography.
- During resuscitation the patient's pelvis should be tilted towards the left side to avoid compression of the inferior vena cava by the gravid uterus. (this may necessitate using a spinal board)
