Trauma basics 3
Remember - Hypoxia and hypotension kill head-injured patients.
- 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.
- 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.
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.
- 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.
- 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)