Transfer Protocol in I CU

Hosam M Atef

Airway

Patients with (or at risk from) airway

compromise should be intubated prior to

transfer

The tracheal tube should be secured and

confirmed in correct position

BreathingPatient adequately sedated if ventilated

Ventilation established (and stable) on transport

ventilator

Adequate gas exchange on transport ventilator

confirmed by arterial blood gas analysis

Adequate oxygen supply on transfer vehicle

Circulation

Adequate intravenous access

Circulating volume optimized

Hemodynamically stable

All lines are patent and secured

Any active bleeding controlled

Long bone/pelvic fractures stabilized

ECG and blood pressure monitored

C. Spine

Adequate spinal immobilization (if indicated)

Disability

No active seizures

Initial treatments for raised intracranial pressure (if

indicated)

Life-threatening electrolyte disturbances corrected

Blood glucose >70 mg/dl

Exposure

Patient adequately covered to prevent heat

loss

Trauma Protocol

Resuscitation protocol in traumatic hemorrhagic shock General principle:

Traumatic death is the main cause of life years lost worldwide.

Hemorrhage is responsible for almost 50% of deaths in the first

24 h after trauma.

The optimal resuscitative strategy is controversial:

Choice of fluid

Target of hemodynamic goals for hemorrhage control

The optimal prevention of traumatic coagulopathy are questions.

Fluid resuscitation I. Type of fluid

Lactated Ringer’s solution is recommended

as first-line resuscitation fluid in trauma

patients

Albumin should be avoided in patients with

TBI

In patients with TBI, isotonic saline should be

preferred over hypotonic fluids because it can

reduce the risk of cerebral edema.

II. Endpoints of resuscitation

Three different target systolic blood pressure values can

be considered for three different traumatic conditions

before controlling source of hemorrhage:

60–70 mmHg for penetrating trauma

80–90 mmHg for blunt trauma without TBI

100–110 mmHg for blunt trauma with TBI

Lactate ≥ 2 mmol/L and base deficits ≥ -5 mEq/L have

been demonstrated useful to stratify patients who need a

larger amount of fluid after the initial resuscitation.

III. Vasopressor

Early use of norepinephrine could limit fluid

resuscitation and hemodilution.

The dose of norepinephrine should be titrated

until we reach the target systolic blood

pressure as indicated above

IV. Transfusion and prevention of acute coagulopathy of trauma

The correction and prevention of traumatic

coagulopathy have become central goals of early

resuscitative management of hemorrhagic shock.

a) Red blood cells

In patients without TBI: Target haemoglobin level

(7-9 g/dL)

In patients with severe TBI (GCS ≤ 8): Target

haemoglobin level ≥ 10 g/dL

a) Fresh Frozen Plasma (FFP)

In all patients FFP should be considered

when PT or PTT ≥ 1.5 times normal value

The initial recommended dose of FFP is 10 to

15 ml/kg

b) Platelet

In patients without TBI: Platelet transfusion

is recommended when platelet count ≤

50.000/L

In patients with TBI: Platelet transfusion is

recommended when platelet count ≤

100.000/L

c) Fibrinogen

In all patients, fibrinogen level should be maintained ≥ 150-

200 mg/dL

If The use of FFP failed to rapidly correct the

hypofibrinogenemia

Resuscitation with 10 to 15 mL/kg of FFP only increased the

fibrinogen plasma level to 40 mg/dL

More than 30 mL.kg of FPP should be necessary to increase

the fibrinogen plasma level to 100 mg/dL

Ten single bags of cryoprecipitate derived from whole blood

are needed to raise the plasma fibrinogen level by 100 mg/dL

d) Adjuvant Therapy

I. Tranxemic acid: routine administration of tranexamic

acid (loading dose of 1 g over 10 min, then infusion of 1g

over 8 hr) in patients with hemorrhagic shock was

associated with a decreased mortality rate.

II. Factor VIIa: No clear recommendation to use activate

factor VII and the use of this factor should be discussed on

a case-by-case basis.

III. Ionized calcium level should be maintained between

1.1-1.3 mmol/L

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