Hypovolemic Shock Management

CMASTCMAST 11

Hypovolemic Shock Hypovolemic Shock ManagementManagement

COMBAT MEDIC ADVANCED SKILLS TRAINING (CMAST)

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IntroductionIntroduction

Basic life-saving steps for the soldier Basic life-saving steps for the soldier medic include:medic include:

– A-B-Cs.A-B-Cs.

– Shock and fluid resuscitationShock and fluid resuscitation..

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Fluid ResuscitationFluid Resuscitation

Control hemorrhage first.Control hemorrhage first. Casualties with significant injuries should Casualties with significant injuries should

have a single 18 ga IV with saline lock in a have a single 18 ga IV with saline lock in a peripheral vein initiated.peripheral vein initiated.

Casualties without significant injuries do Casualties without significant injuries do not need an IV but should be encouraged not need an IV but should be encouraged to drink fluids.to drink fluids.

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Saline Lock KitSaline Lock Kit

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Saline LockSaline Lock

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Fluid ResuscitationFluid Resuscitation If unable to start a peripheral IV consider If unable to start a peripheral IV consider

initiating a sternal I/O.initiating a sternal I/O.

F.A.S.T.1

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F.A.S.T.1F.A.S.T.1

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Intraosseous AccessIntraosseous Access

Sternal vs. tibial.Sternal vs. tibial. Majority of wounds are Majority of wounds are

extremity wounds (> 60%).extremity wounds (> 60%). Tibial cortex is very thick.Tibial cortex is very thick. Sternum protected by body Sternum protected by body

armor.armor. Sternum is uniform from Sternum is uniform from

person to person.person to person.

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Intraosseous AccessIntraosseous Access Indications:Indications:

─ Inadequate peripheral accessInadequate peripheral access─ Need for rapid access for medications, Need for rapid access for medications,

fluid or bloodfluid or blood─ Failed attempts at peripheral or central Failed attempts at peripheral or central

venous accessvenous access

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Intraosseous AccessIntraosseous Access Typical protocol precautions:Typical protocol precautions: F.A.S.T.1 not recommended if:F.A.S.T.1 not recommended if:

─ Casualty is of small stature:Casualty is of small stature:Weight is less than 50 kg.Weight is less than 50 kg.

Pathological small size Pathological small size

─ Fractured manubrium/sternum - flailFractured manubrium/sternum - flail─ Significant tissue damage at siteSignificant tissue damage at site─ Severe osteoporosisSevere osteoporosis─ Previous sternotomy and/or scarPrevious sternotomy and/or scar

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Flow CapabilitiesFlow Capabilities

30 ml/min by gravity.30 ml/min by gravity. 125 ml/min utilizing 125 ml/min utilizing

pressure infusion.pressure infusion. 250 ml/min using 250 ml/min using

syringe forced syringe forced infusion.infusion.

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Administering BloodAdministering Blood

Blood is 4 times more viscous than NaCl.Blood is 4 times more viscous than NaCl. Result is 1/4 normal rate of flow when Result is 1/4 normal rate of flow when

administering blood using gravity.administering blood using gravity. Infusion catheter internal pressure during Infusion catheter internal pressure during

gravity infusion = ~75 mmHg.gravity infusion = ~75 mmHg. Catheter can take up to 1,500 mmHg.Catheter can take up to 1,500 mmHg. Solution? Solution?

─ Use pressure infusionUse pressure infusion

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F.A.S.T.1 is considered a short-tem device and F.A.S.T.1 is considered a short-tem device and should not to be left in place for should not to be left in place for > 24 hours> 24 hours..

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Perpendicular InsertionPerpendicular Insertion

F.A.S.T.1 must be inserted perpendicular to F.A.S.T.1 must be inserted perpendicular to the surface of the manubrium.the surface of the manubrium.

Device penetrates bone only 6 mm.Device penetrates bone only 6 mm. Perpendicular relationship to the surface of Perpendicular relationship to the surface of

the manubrium critical for catheter to enter the manubrium critical for catheter to enter marrow space.marrow space.

Rich vasculature drains manubrium… Rich vasculature drains manubrium… F.A.S.T.1 is equivalent to a peripheral IV.F.A.S.T.1 is equivalent to a peripheral IV.

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Perpendicular InsertionPerpendicular Insertion Confirm landmarks:Confirm landmarks:

– Manubrium is Manubrium is upper aspect of upper aspect of sternal structuresternal structure

– Articulates with Articulates with body of sternum at body of sternum at the “Angle of the “Angle of Louis”Louis”

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Note that there are Note that there are three planes relative three planes relative to the casualty:to the casualty:

1-Surface of ground1-Surface of ground

2-Surface of body of 2-Surface of body of the sternumthe sternum

3-Surface of the 3-Surface of the manubriummanubrium

1

3

2

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Manubrium surface Manubrium surface angle is your point of angle is your point of focus.focus.

Perpendicular means Perpendicular means at right angles to the at right angles to the surface of the surface of the manubrium.manubrium.

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F.A.S.T.1 ProcedureF.A.S.T.1 Procedure

Procedure:Procedure:– Prepare site using aseptic techniquePrepare site using aseptic technique

• BetadineBetadine• AlcoholAlcohol

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Insertion:Insertion:– Finger at suprasternal notchFinger at suprasternal notch– Align finger with patch indentationAlign finger with patch indentation– Emplace patchEmplace patch

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Insertion:Insertion:– Place introducer needle cluster in target areaPlace introducer needle cluster in target area

• Assure firm gripAssure firm grip• Introducer device Introducer device

must be must be perpendicular to perpendicular to the surface of the the surface of the manubriummanubrium

Insertion:Insertion:– Place introducer needle cluster in target areaPlace introducer needle cluster in target area

• Assure firm gripAssure firm grip• Introducer device Introducer device

must be must be perpendicular to perpendicular to the surface of the the surface of the manubriummanubrium

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F.A.S.T.1 ProcedureF.A.S.T.1 Procedure Insertion:Insertion:

– Insert using increasing pressure till device Insert using increasing pressure till device releases (~20-30 pounds) releases (~20-30 pounds)

NOTENOTE: If more force than that is needed, it’s not : If more force than that is needed, it’s not perpendicular)perpendicular)

– Maintain Maintain perpendicular perpendicular alignment to the alignment to the manubrium manubrium throughoutthroughout

Insertion:Insertion:– Insert using increasing pressure till device Insert using increasing pressure till device

releases (~20-30 pounds) releases (~20-30 pounds) NOTENOTE: If more force than that is needed, it’s not : If more force than that is needed, it’s not

perpendicular)perpendicular)– Maintain Maintain

perpendicular perpendicular alignment to the alignment to the manubrium manubrium throughoutthroughout

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Insertion:Insertion:– Following device release, infusion tube Following device release, infusion tube

separates from introducerseparates from introducer– Remove introducer by pulling straight backRemove introducer by pulling straight back– Cap introducer Cap introducer

using post-use using post-use cap suppliedcap supplied

Insertion:Insertion:– Following device release, infusion tube Following device release, infusion tube

separates from introducerseparates from introducer– Remove introducer by pulling straight backRemove introducer by pulling straight back– Cap introducer Cap introducer

using post-use using post-use cap suppliedcap supplied

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F.A.S.T.1 ProcedureF.A.S.T.1 Procedure Insertion:Insertion:

– Connect infusion tube to tube on the target Connect infusion tube to tube on the target patchpatch

– Assure patency by use of syringe administer Assure patency by use of syringe administer 5 ml blast of saline5 ml blast of saline• Clears any Clears any

tissue debris in tissue debris in the infusion the infusion cathetercatheter

Insertion:Insertion:– Connect infusion tube to tube on the target Connect infusion tube to tube on the target

patchpatch– Assure patency by use of syringe administer Assure patency by use of syringe administer

5 ml blast of saline5 ml blast of saline• Clears any Clears any

tissue debris in tissue debris in the infusion the infusion cathetercatheter

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Insertion:Insertion:─ Connect IV line to target patch tubeConnect IV line to target patch tube─ Open IV and ensure good solution flow Open IV and ensure good solution flow

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Insertion:Insertion:– Emplace the dome over the siteEmplace the dome over the site

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Insertion:Insertion:– Be certain that remover device is attached to Be certain that remover device is attached to

(and transported with) the casualty(and transported with) the casualty

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F.A.S.T.1 ProcedureF.A.S.T.1 Procedure Problems areas:Problems areas:

– Infiltration - usually due to insertion not being Infiltration - usually due to insertion not being perpendicular to the manubriumperpendicular to the manubrium

– Inadequate flow or no flow -Inadequate flow or no flow -• Infusion tube occludedInfusion tube occluded• 1 ml saline flush recommended1 ml saline flush recommended• Infusion catheter inserted at other than a Infusion catheter inserted at other than a

perpendicular angle to the manubrium perpendicular angle to the manubrium surfacesurface

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Removal procedure:Removal procedure:– Stabilize target patch with one handStabilize target patch with one hand– Remove dome with the otherRemove dome with the other

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Removal procedure:Removal procedure:– Terminate IV fluid flowTerminate IV fluid flow– Disconnect infusion tubeDisconnect infusion tube

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F.A.S.T.1 ProcedureF.A.S.T.1 Procedure Removal procedure:Removal procedure:

– Hold infusion tube Hold infusion tube perpendicular to the perpendicular to the manubriummanubrium

– Maintain slight traction Maintain slight traction on the infusion tubeon the infusion tube

– Insert the remover while Insert the remover while continuing to hold infusion continuing to hold infusion tube in slight tractiontube in slight traction

Removal procedure:Removal procedure:– Hold infusion tube Hold infusion tube

perpendicular to the perpendicular to the manubriummanubrium

– Maintain slight traction Maintain slight traction on the infusion tubeon the infusion tube

– Insert the remover while Insert the remover while continuing to hold infusion continuing to hold infusion tube in slight tractiontube in slight traction

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– Advance removerAdvance remover– THIS IS A THREADED THIS IS A THREADED

DEVICEDEVICE– Gentle counterclockwise Gentle counterclockwise

movement at first may help movement at first may help in seating remover in seating remover

– Make sure you feel the Make sure you feel the threads seatthreads seat

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– Turn it clockwise until Turn it clockwise until remover no longer turnsremover no longer turns

– This firmly engages This firmly engages remover into metal remover into metal (proximal) end of the (proximal) end of the infusion tubeinfusion tube

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– Remove infusion Remove infusion tubetube

– Use only “T” shaped Use only “T” shaped knob and pull knob and pull perpendicular to the perpendicular to the manubriummanubrium

– Hold target patch Hold target patch during removalduring removal

– DO NOT pull on the DO NOT pull on the Luer fitting or the Luer fitting or the tube itselftube itself

Removal procedure:Removal procedure:– Remove infusion Remove infusion

tubetube– Use only “T” shaped Use only “T” shaped

knob and pull knob and pull perpendicular to the perpendicular to the manubriummanubrium

– Hold target patch Hold target patch during removalduring removal

– DO NOT pull on the DO NOT pull on the Luer fitting or the Luer fitting or the tube itselftube itself

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– Remove target patchRemove target patch

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– Dress infusion site using aseptic techniqueDress infusion site using aseptic technique– Dispose of remover and infusion tube using Dispose of remover and infusion tube using

contaminated sharps protocolcontaminated sharps protocol

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– Problems encountered during removalProblems encountered during removal• Performed properly…should be none!Performed properly…should be none!• Be certain threads on remover engage Be certain threads on remover engage

threads at distal end of infusion catheterthreads at distal end of infusion catheter• Moving remover around with tip as axis Moving remover around with tip as axis

while in the infusion catheter may shear off while in the infusion catheter may shear off end of removal toolend of removal tool

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– If removal fails or proximal metal ends If removal fails or proximal metal ends separates:separates:• Anesthetize with local - make small incisionAnesthetize with local - make small incision• Remove using clamp and close as Remove using clamp and close as

appropriateappropriate

NOTENOTE: This is “serious injury” as defined by : This is “serious injury” as defined by the FDA and is a reportable eventthe FDA and is a reportable event

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Intravenous SolutionsIntravenous Solutions Different types of IV fluids can be used Different types of IV fluids can be used

for different medical conditionsfor different medical conditions

Generally categorized Generally categorized as:as:– Colloid or CrystalloidColloid or Crystalloid

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ColloidsColloids Contain protein, sugar or other high Contain protein, sugar or other high

molecular weight molecules; used to expand molecular weight molecules; used to expand intravascular volume.intravascular volume.– Whole blood (most common)Whole blood (most common)– Packed red blood cellsPacked red blood cells– Fresh frozen plasma Fresh frozen plasma – Plasma Protein FractionPlasma Protein Fraction– Hypertonic Saline & Dextran (HSD)Hypertonic Saline & Dextran (HSD)– Hextend is a 6% hetastarch solution Hextend is a 6% hetastarch solution

in a balanced electrolyte solutionin a balanced electrolyte solution

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CrystalloidsCrystalloids Solutions that do not contain protein or other Solutions that do not contain protein or other

large molecules; sodium is the primary osmotic large molecules; sodium is the primary osmotic agent.agent.

These fluids do not remain in the vascular These fluids do not remain in the vascular system very long.system very long.– Normal Saline (NS, 0.9% NaCl)Normal Saline (NS, 0.9% NaCl)– Lactated Ringers (LR)Lactated Ringers (LR)

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FluidsFluids Fluid distribution.Fluid distribution.

– Intracellular space = 2/3 of body weight.Intracellular space = 2/3 of body weight.– Extracellular space = 1/3 of body weight.Extracellular space = 1/3 of body weight.

• Interstitial space 80% Interstitial space 80% • Vascular space 20%Vascular space 20%

ICFICF

ICFICFECFECF

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FluidsFluids 1,000 ml of Ringers Lactate (2.4 lbs) will 1,000 ml of Ringers Lactate (2.4 lbs) will

expand the intravascular volume by expand the intravascular volume by 200-250 ml within 1 hour.200-250 ml within 1 hour.

Why only 200-250 ml left?Why only 200-250 ml left?

– Sodium diffuses out of the blood vessels into Sodium diffuses out of the blood vessels into the extravascular (interstitial) space rapidly.the extravascular (interstitial) space rapidly.

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HextendHextend 500ml of Hextend500ml of Hextend®® weighs 1.3lbs will weighs 1.3lbs will

expand the intravascular volume by 800ml expand the intravascular volume by 800ml within 1 hour, and will sustain this within 1 hour, and will sustain this expansion for 8 hours.expansion for 8 hours.

How does this happen?How does this happen?

Large sugar molecule-pulls fluid from the Large sugar molecule-pulls fluid from the extra vascular (interstitial) space into the extra vascular (interstitial) space into the vessels.vessels.

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FluidsFluids One liter of Hextend = 6-8 liters of RL.One liter of Hextend = 6-8 liters of RL. Is it a better resuscitation fluid?Is it a better resuscitation fluid? No, it is better for hypovolemia because of No, it is better for hypovolemia because of

its weight and cube advantage for the its weight and cube advantage for the soldier medic.soldier medic.

Ringers lactate is better for dehydration.Ringers lactate is better for dehydration. Soldier medics must carry some of each.Soldier medics must carry some of each.

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Resuscitation IndicatorsResuscitation Indicators How do you determine who needs fluids?How do you determine who needs fluids? Blood Pressure.Blood Pressure. Peripheral (radial) pulse.Peripheral (radial) pulse. Can BP be measured in a combat environment?Can BP be measured in a combat environment?

– HelicoptersHelicopters– TracksTracks– Battlefield conditionsBattlefield conditions

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Hypotensive ResuscitationHypotensive Resuscitation

Casualties should only be resuscitated to Casualties should only be resuscitated to a blood pressure of 80 mmHg.a blood pressure of 80 mmHg.

If blood vessels have clotted can you raise If blood vessels have clotted can you raise the blood pressure high enough to pop the the blood pressure high enough to pop the clot off?clot off?

– YES at a BP of @ 93 mmHg YES at a BP of @ 93 mmHg

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Resuscitation IndicatorsResuscitation Indicators

The systolic blood pressure may be The systolic blood pressure may be approximated by palpating specific pulses: approximated by palpating specific pulses:

─ Palpable carotid pulse = 60 mmHgPalpable carotid pulse = 60 mmHg─ Palpable femoral pulse = 70 mmHgPalpable femoral pulse = 70 mmHg─ Palpable radial pulse = 80 mmHgPalpable radial pulse = 80 mmHg

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Superficial wounds (>50% injured); no Superficial wounds (>50% injured); no immediate IV fluids needed. Oral fluids immediate IV fluids needed. Oral fluids should be encouraged.should be encouraged.

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Any significant extremity or truncal wound Any significant extremity or truncal wound (neck, chest, abdomen, pelvis).(neck, chest, abdomen, pelvis).

If the casualty is coherent and has a If the casualty is coherent and has a palpable radial pulse (BP 80 mmHg), palpable radial pulse (BP 80 mmHg), initiate a saline lock, hold fluids and initiate a saline lock, hold fluids and reevaluate as frequently as the situation reevaluate as frequently as the situation permits.permits.

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Fluid ResuscitationFluid Resuscitation If casualty has a palpable radial pulse, why If casualty has a palpable radial pulse, why

initiate a saline lock?initiate a saline lock?

─ By establishing intravenous access now, By establishing intravenous access now, when they have an adequate BP, it is easier when they have an adequate BP, it is easier than when they have a lower/absent BP.than when they have a lower/absent BP.

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Fluid ResuscitationFluid Resuscitation Significant blood loss from any wound, and Significant blood loss from any wound, and

the soldier has no radial pulse or is not the soldier has no radial pulse or is not coherent coherent --STOP THE BLEEDINGSTOP THE BLEEDING-- by by whatever means available - tourniquet, direct whatever means available - tourniquet, direct pressure, hemostatic dressings, or pressure, hemostatic dressings, or hemostatic powder etc. hemostatic powder etc.

Start 500 ml of HextendStart 500 ml of Hextend®®. If mental status . If mental status improves and radial pulse returns, maintain improves and radial pulse returns, maintain saline lock and hold fluids. saline lock and hold fluids.

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If no response is seen give an additional 500 ml If no response is seen give an additional 500 ml of Hextendof Hextend® ® and monitor vital signs. If no and monitor vital signs. If no response is seen after 1,000 ml of Hextendresponse is seen after 1,000 ml of Hextend®®, , consider triaging supplies and attention to more consider triaging supplies and attention to more salvageable casualties.salvageable casualties.

Why?Why?─ Resources: How many more casualties do you have Resources: How many more casualties do you have

and how much fluid is available?and how much fluid is available?

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If casualties are not resuscitated with 1,000ml of If casualties are not resuscitated with 1,000ml of Hextend they are probably still bleeding. If Hextend they are probably still bleeding. If excess fluids are given they will die faster than a excess fluids are given they will die faster than a casualty who received no fluids.casualty who received no fluids.

Why? Increased BP and coagulation factors Why? Increased BP and coagulation factors diluted as BP rises hemorrhage increasesdiluted as BP rises hemorrhage increases

Why then does ATLS recommend 2 large-bore Why then does ATLS recommend 2 large-bore IVs and fluid run wide open? The transit time to IVs and fluid run wide open? The transit time to definitive care is only a few minutes.definitive care is only a few minutes.

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Why does hypothermia happen?Why does hypothermia happen?

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HypothermiaHypothermia

Casualties who are hypovolemic quickly Casualties who are hypovolemic quickly become hypothermic.become hypothermic.

Body temperatures below 91°Body temperatures below 91° F F causes causes the vicious triad.the vicious triad.– HypothermiaHypothermia– AcidosisAcidosis– CoagulopathyCoagulopathy

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HypothermiaHypothermia When this vicious triad occurs the When this vicious triad occurs the

casualty’s blood will not clot. casualty’s blood will not clot.

Prevention is the best method.Prevention is the best method.

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Field Expedient WarmingField Expedient Warming Warm IV fluids in cold environment.Warm IV fluids in cold environment.

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HypothermiaHypothermia Prior to evacuation, casualties must be Prior to evacuation, casualties must be

wrapped in a blanket to prevent heat loss wrapped in a blanket to prevent heat loss during transport (even if the temperature is during transport (even if the temperature is 120°120° F F) especially true with air evacuation) especially true with air evacuation

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Hypothermia Prevention and Hypothermia Prevention and Management KitManagement Kit™™

Contents:1 x Heat Reflective Shell1 x Self Heating, Four Cell Shell Liner 1 x Heat Reflective Skull Cap

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Hypothermia Prevention and Hypothermia Prevention and Management Kit™ (HPMK)Management Kit™ (HPMK)

Ready for TransportReady for Transport

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6 – Cell

“Ready-Heat” Blanket

4- Cell

“Ready-Heat” Blanket

Blizzard “Survival

Wrap

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Summary Summary

Identify hypovolemic shock.Identify hypovolemic shock.

Ensure hemorrhage control first.Ensure hemorrhage control first.

Provide treatment for hypovolemic shock Provide treatment for hypovolemic shock using hypotensive resuscitation principles.using hypotensive resuscitation principles.

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Questions?Questions?

Hypovolemic Shock Management

Education

Transcript of Hypovolemic Shock Management