1st priority: restore volume with fluid.• Two large bore IVs (14 or 16 gauge)
*Shorter tubing provides faster IV rate
2nd prority: restore volume with Whole Blood and transfusion.
• Judicious use of crystalloid in Class II Hemorrhage or higher*ATLS and textbooks still describe the use of NS or LR for 1-2 Liter bolus*However, new guidelines suggest limiting crystalloid in favor of Blood Products
3rd priority: normalize coagulation status with FFP, platelets and blood products.
• Hemorrhage should be replaced with Blood Products*Indications
• Mean arterial pressure 65 (or systolic Blood Pressure 70-90 mmHg)
• Poor response to IV fluids– Persistent Tachycardia, Hypotension or Tachyp
nea– Urine output <50 ml/hour (<1ml/kg/hour)
*Start with 2 units (prepare 4 units pRBC for more severe Hemorrhage)
• Type specific blood can be ready within 30-40 minutes
• In the crashing patient give unmatched type-specific blood, Low titer O or O negative blood
*Massive Hemorrhage with administration of more than 4 units requires matching Blood Products*Consider autotransfusion (e.g. Hemovac or Cell Saver)
• Indicated for massive bleeding if blood can be drained and not contaminated)
*Consider blood warmer
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