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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.

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fluid resuscitation

FLUID RESUSCITATION

CURRENT THINKING

Dr Sean R Santos

CGH

objectives
Objectives
  • Define Shock
  • Consider methods for recognising the shocked casualty
  • Discuss pre-hospital management
  • In-hospital Management
  • Future Developments
shock

Shock

Failure to achieve adequate perfusion and oxygenation of the tissues

types of shock
Types of shock
  • Hypovolaemic
  • Cardiogenic Inc Tamponade/Tension
  • Septic
  • Neurogenic
  • Anaphylactic
class i 750 ml 15
Class I 750 mL (15%)
  • Slightly anxious
  • Normal blood pressure
  • Heart rate < 100 / min
  • Respirations 14-20 / min
  • Urinary output 30 mL / hour
  • Warm skin, Normal Cap Refill
class ii 750 1500 ml 15 30
Class II 750-1500 mL (15-30%)
  • Anxious
  • Normal blood pressure
  • Heart rate > 100 / min
  • Decreased pulse pressure
  • Respirations 20-30 / min
  • Urinary output 20-30 mL / hour
  • Pale, Cool, Cap Refill Delayed
class iii 1500 2000 ml 30 40
Class III 1500-2000 mL (30-40%)
  • Confused, anxious
  • Decreased blood pressure
  • Heart rate > 120 / min
  • Decreased pulse pressure
  • Respirations 30-40 / min
  • Urinary output 5-15 mL / hour
  • V. Pale, Sweaty, Cap refill V Delayed
class iv 2000 ml 40
Class IV >2000 mL (>40%)
  • Confused, lethargic
  • Hypotension
  • Heart rate > 140 / min
  • Decreased pulse pressure
  • Respirations >35 / min
  • Urinary output negligible
pulses
Pulses
  • Radial 70-80 mmHg
  • Femoral 60-70 mmHg
  • Carotid ≤60 mmHg
early indicators
Early Indicators
  • Resp Rate
  • Colour
  • Cap refill
  • Mental State
management

Management

Historical

New Strategies

historical
Historical
  • Two Large Bore Cannulae
  • Two Litres Of Fluid
  • Continue Replacement until HR Normal
  • Control Bleeding
new strategies

New Strategies

Preservation

Bleeding Control

Fluid Management

preservation
Preservation
  • Rapid Transfer
  • Surgical/Radiological Management of Bleeding
  • Permissive Hypotension
  • Immobilisation of Fractures
  • Gentle Handling to preserve Clot
preservation visible haemorrhage
PreservationVisible Haemorrhage
  • Direct Pressure
  • Indirect Pressure
  • Tourniquet
tourniquets
Tourniquets
  • Proximal
  • Adequate Pressure
  • Communication, Orange for Visibility
  • Aim for max 2 hours
  • Adequate facilities on release
clot promotion
Clot Promotion
  • Quick Clot
  • Dressings
  • Fibrin Sealants
fluid management
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

Colloids vs. Crystalloids
not what

Not What

How Much

how much
How Much
  • Pulse Nothing
  • No pulse 250ml Bolus ? Response ? Repeat
  • Unconscious Measure BP ≤100 mmHg 250ml ≥100 mmHg Nothing
route
Route
  • Big IV Cannula
  • Intra Osseous
current future developments
Current/Future Developments
  • Hypertonic Solutions
  • Damage Control Resuscitation
  • Damage Control Surgery
hypertonic solutions
Hypertonic Solutions
  • 5, 7.5, 10%Saline
  • +/- Colloid
  • Rapid, Sustained BP increase
  • Small Volume
  • Diuresis
  • ↓ Intracranial Pressure
damage control resuscitation

Damage Control Resuscitation

Damage Control Surgery

damage control resuscitation1
Damage Control Resuscitation
  • Lethal Triad Hypothermia Acidosis Coagulopathy
damage control resuscitation2
Damage Control Resuscitation
  • Permissive Hypotension
  • Haemostatic Resuscitation
  • Damage Control Surgery
haemostatic resuscitation
Haemostatic Resuscitation
  • Packed Cell 1unit
  • FFP 1unit
  • Platelets 1 bag/4-6
  • Calcium, Tranexamic Acid, Factor VIIa
conclusions

Conclusions

Recognition

Preservation

Small Volume Resuscitation

Control Of Bleeding