Fluids in Trauma 2013
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Transcript of Fluids in Trauma 2013
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FLUID RESUSCITATION IN
TRAUMA – AN UPDATE
Dr Sashi Kumar
Senior Staff Specialist
Emergency Medicine
The Canberra HospitalAUSTRALIA
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EMERGENCY DEPARTMENT
THE CANBERRA HOSPITAL
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FLUIDS IN TRAUMA –
A HISTORICAL UP DATE
1600 - WILLIAM HARVEY
CIRCULATION OF BLOOD
( AIR GOES IN AND OUTBLOOD GOES ROUND AND ROUND )
1800 – PHYSIOLOGICAL SALINE
1900 – MAJOR BLOOD TYPES
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HISTORY - CONTINUED• WORLD WAR 1 –CANNON ET AL 1918
• “IF THE PRESSURE IS RAISED WITHOUT A
SURGEON TO CHECK THE BLEEDING
BLOOD WILL BE LOST”
• VIETNAM WAR 1960S – LARGE VOLUME CRYSTALLOID RESUSCITATION –MADE SENSE
http://www.vietnam-war.0catch.com/vietnam_war_pics/vietnam_war_pics/wp17.jpghttp://www.vietnam-war.0catch.com/vietnam_war_pics/vietnam_war_pics/wp32.jpg
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Old Doctrine
- Give 2 litres of Ringers Lactate and watch the response !
- ATLS 7th edition early 1990 s
Large bore cannulae x 2(at least)
Level 1 Blood warmer
Continue to fill up !
Stay in the race !
Faster !Faster !Faster !
http://www.google.com.au/imgres?imgurl=http://www.trauma.org/images/image_library/21223463721July_125.jpg&imgrefurl=http://www.trauma.org/index.php/main/image/754/&usg=__I0_Gwh43Dt2UblB4ospkdGLZj6E=&h=1357&w=1783&sz=224&hl=en&start=50&zoom=1&tbnid=A0mjvPzEOTdkBM:&tbnh=114&tbnw=150&ei=fWckUer9BYf-lAWWkIHIBg&prev=/search%3Fq%3DTRAUMA%26start%3D40%26hl%3Den%26sa%3DN%26rls%3Dcom.microsoft:en-au%26biw%3D2276%26bih%3D1113%26ie%3DUTF-8%26tbm%3Disch&itbs=1&sa=X&ved=0CDwQrQMwCTgo
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Pre Hospital Phase
• Houston Texas
• NEJM OCT 1994
• 598 patients
• SBP
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PRE HOSPITAL CARE –
CRITICAL GOALS
• 1 . STOP THE EXTERNAL BLEEDING
• 2 . RAPID TRANSPORT
•3 . RESUSCITATE TO MAINTAINMENTAL STATUS AND PERIPHERAL
PULSES
http://esa.act.gov.au/community-information/calling-an-ambulance/
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PRE HOSPITAL CARE• A PROSPECTIVE MULTICENTRE CANADIAN STUDY IN 2003
ANNALS OF SURGERY• 9405 PATIENTS
• INCREASED MORTALITY WITH EVERY ATLS INTERVENTION
• SEAMON ET AL – RETROSPECTIVE STUDY J TRAUMA 2007
• 180 PENETRATING TRAUMA REQUIRING ED THORACOTOMY
•PRE HOSPITAL PROCEDURES
– INDEPENDENT PREDICTOROF BAD OUTCOME
• VASCULAR ACCESS NOT ESSENTIAL
• MINIMAL FLUIDS IF PULSE PRESENT
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FLUIDS - How much of what ?
• How much ?
• How fast ?
• What fluid ?
• For How long ?
What is stable?
STABLE IS A
STATE OF MIND !
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Permissive Hypotension
• Do not drown your patients !
• Accept Lower BP
• Radial pulse –enough
• Do the ATLS/CTLS dance and
stop the bleed ing !
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LACTATED RINGER SOLUTION• CREATED BY HARTMANN IN 1930S
• METABOLISED IN LIVER TO PYRUVATE OR
CO2 AND H2O
• RELEASE OF HYDROXIDE WHICH IS
CONVERTED TO BICARBONATE• OFFERS PHYSIOLOGICAL BUFFER TO
ACIDOSIS
http://www.google.com.au/imgres?imgurl=http://www.medshop.co.nz/image/cache/data/file_33_11-500x500.jpg&imgrefurl=http://www.medshop.co.nz/lactated-ringers-1000-mls&usg=__HiiUv0zGMNsu8JyVb3GNEn6BXQs=&h=500&w=500&sz=115&hl=en&start=11&zoom=1&tbnid=D0EuXd5C0T0vYM:&tbnh=130&tbnw=130&ei=HjokUdeIPMiAkQXLuoCAAw&prev=/search%3Fq%3Dlactated%2Bringer%2527s%26hl%3Den%26sa%3DN%26rls%3Dcom.microsoft:en-au%26biw%3D2276%26bih%3D1113%26ie%3DUTF-8%26tbm%3Disch&itbs=1&sa=X&ved=0CD4QrQMwCg
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COLLOIDS
• SALINE VS ALBUMIN FLUID EVALUATION( SAFE ) STUDY NEJM 2004
• 7000 CRITICALLY ILL ICU PATIENTS
• 4 % ALBUMIN VS N SALINE
• NO BENEFICIAL EFFECTS ONMORTALITY MORBIDITY OR LOS IN ICU
• COCHRANE REVIEW IN 2007 -
•NO REDUCTION IN DEATH / EXPENSIVE
NORMAL SALINE
http://www.google.com.au/imgres?imgurl=http://www.transfusion.com.au/sites/default/files/Albumex_4_20g-small.jpg&imgrefurl=http://www.transfusion.com.au/blood_products/fractionated_plasma/albumin&usg=__AxFmphYMVo82OlLNZO6wE07br0c=&h=328&w=248&sz=22&hl=en&start=1&zoom=1&tbnid=zMEa2l9o6ThhSM:&tbnh=118&tbnw=89&ei=ez4kUYiYEsebkgW96oDIDA&prev=/search%3Fq%3D4%2B%2525%2BALBUMIN%26hl%3Den%26sa%3DX%26rls%3Dcom.microsoft:en-au%26biw%3D2276%26bih%3D1113%26ie%3DUTF-8%26tbm%3Disch&itbs=1&sa=X&ved=0CCoQrQMwAA
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NORMAL SALINE• CAUSES HYPERCHLOREMIC ACIDOSIS
WHEN GIVEN IN LARGE VOLUMES
• UNCONTROLLED HAEMORRHAGICSHOCK IN PIGS – TODD ET AL 2007
• HIGHER VOLUME REQUIRED / MORE
ACIDOTIC / LOWER FIBRINOGEN ANDWORSE COAGULOPATHY
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RESUSCITATION INJURY
CAPILLARY PERMEABILITY INCREASES
CELLULAR SWELLING AND DYSFUNCTION
FLUID OVERLOAD AND OEDEMA BEGETS FURTHER
FLUIDS AND OEDEMAVIETNAM WAR – ACUTE LUNG INJURY DA NANG LUNG
ADULT RESPIRATORY DISTRESS SYNDROME ( ARDS )
ABDOMINAL COMPARTMENT SYNDROME
http://www.google.com.au/imgres?imgurl=http://upload.wikimedia.org/wikipedia/en/thumb/9/94/7_RAR_Vietnam_(AWM_EKN-67-0130-VN).jpg/300px-7_RAR_Vietnam_(AWM_EKN-67-0130-VN).jpg&imgrefurl=http://en.wikipedia.org/wiki/Military_history_of_Australia_during_the_Vietnam_War&usg=__bFs6W3xgMQHBw3uJ7OeB7uW9Rzs=&h=249&w=300&sz=28&hl=en&start=8&zoom=1&tbnid=pavrtsVJoMIqlM:&tbnh=96&tbnw=116&ei=VXAkUbSsL8OTkQW74IGYCw&prev=/search%3Fq%3Dvietnam%2Bwar%26hl%3Den%26sa%3DX%26rls%3Dcom.microsoft:en-au%26biw%3D2276%26bih%3D1113%26ie%3DUTF-8%26tbm%3Disch&itbs=1&sa=X&ved=0CDgQrQMwBwhttp://www.vietnam-war.0catch.com/vietnam_war_pics/vietnam_war_pics/wp31.jpghttp://www.vietnam-war.0catch.com/vietnam_war_pics/vietnam_war_pics/wp6.jpg
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HYPERTONIC SALINE
SINCE 1980SVOLUME EXPANSION AND RESTORATION OF
T CELL FUNCTION IN ANIMAL STUDY – 1997
COCHRANE REVIEW 2004
NO DIFFERENCE IN MORTALITY BETWEENHYPERTONIC AND ISOTONIC SALINE
COOPER ET AL – JAMA 2004 PROSPECTIVERANDOMISED STUDY
RCT 229 PATIENTS WITH TBI 250 MLS 7.5%SALINEVS RINGERS
NO DIFFERENCE IN MORTALITY OR GLASGOWOUTCOME SCALE EXTENDED ( GOSE )
http://www.google.com.au/imgres?imgurl=http://www.valleyvet.com/swatches/308RX_L_vvs_000.jpg&imgrefurl=http://www.valleyvet.com/ct_detail.html%3Fpgguid%3D30e079fb-7b6a-11d5-a192-00b0d0204ae5&usg=__RYWNI2MU4Om5-vaAtemBQPWVrts=&h=2114&w=778&sz=681&hl=en&start=4&zoom=1&tbnid=5J5pPBnWBNuRrM:&tbnh=150&tbnw=55&ei=rkckUdaDKoWikgXh6oDoDw&prev=/search%3Fq%3Dhypertonic%2Bsaline%26hl%3Den%26sa%3DX%26rls%3Dcom.microsoft:en-au%26biw%3D2276%26bih%3D1113%26ie%3DUTF-8%26tbm%3Disch&itbs=1&sa=X&ved=0CDAQrQMwAw
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GIVE BLOOD EARLY
• Do not fill up with fluids
• Do not cheat
• Emphasis on early blood
and products
•Stop the bleed ing
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BLOOD substitutes
• Ideal fluid
• safe
• Carries O2
• Cheap
• Easy to store
•More research needed
• New developments in Fluid resuscitation - Hasan B Alam
Surgical clinics of N America Feb 2007
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SUMMARY
PRE HOSPITAL PHASE
• RAPID TRANSPORT
• AVOID TIME CONSUMING ATLS
PROCEDURES - LEVEL II• IV ACCESS NOT MANDATORY
• IV FLUIDS TO KEEP VEIN OPEN
• RESUSCITATE TO ADEQUATE MENTALSTATUS AND PERIPHERAL PULSES
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SUMMARY – IN ED• CHOICE OF FLUID
- NO EFFECT ON OUTCOME LEVEL I
• LACTATED RINGER HAS
THEORETICAL ADVANTAGES LEVEL III
• AVOID LARGE VOLUME CRYSTALLOID
RESUSCITATION LEVEL III
•UNCONTROLLED HAEMORRHAGE ANDNO TBI SBP 70 – 90 LEVEL III
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SUMMARY –IN ED
•INITIATE MASSIVE TRANSFUSIONPROTOCOL IN SELECTED PATIENTS
• USE FIXED RATIOS OF BLOOD AND BLOOD
PRODUCTS LEVEL II
• GIVE TRANEXAMIC ACID TO ALL PATIENTSWITH UNCONTROLLED HAEMORRHAGE
AND REQUIRING TRANSFUSION LEVEL I
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CONCLUSION
• DEBATE CONTINUES ON IDEAL FLUID IN TRAUMA
RESUSCITATION
• NO DIFFERENCE BETWEEN COLLOID AND
CRYSTALLOID
• AVOID LARGE VOLUMES OF N SALINE
• USE BLOOD AND BLOOD PRODUCTS EARLY
• STOP THE BLEEDING !
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REMEMBER
“NOT EVERYTHING THAT COUNTS CAN
BE COUNTED AND NOT EVERYTHING
THAT CAN BE COUNTED COUNTS’’
(ALBERT EINSTEIN )
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