FLUID RESUSCITATION CURRENT THINKING Dr Sean R Santos CGH.

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Presentation transcript:

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 / min ● Urinary output 30 mL / hour ● Warm skin, Normal Cap Refill

Class II mL (15-30%) ● Anxious ● Normal blood pressure ● Heart rate > 100 / min ● Decreased pulse pressure ● Respirations / min ● Urinary output mL / hour ● Pale, Cool, Cap Refill Delayed

Class III mL (30-40%) ● Confused, anxious ● Decreased blood pressure ● Heart rate > 120 / min ● Decreased pulse pressure ● Respirations / 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 Radial70-80 mmHg Femoral60-70 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

Preservation Visible Haemorrhage Direct Pressure Indirect Pressure 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

PulseNothing No pulse250ml Bolus ? Response ? Repeat UnconsciousMeasure 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 TriadHypothermia Acidosis Coagulopathy

Damage Control Resuscitation Permissive Hypotension Haemostatic Resuscitation Damage Control Surgery

Haemostatic Resuscitation Packed Cell1unit FFP1unit Platelets1 bag/4-6 Calcium, Tranexamic Acid, Factor VIIa

Damage Control Surgery

?

Conclusions Recognition Preservation Small Volume Resuscitation Control Of Bleeding