Fluid management in Fluid management in trauma and burntrauma and burn

Dr Osama BawazirAssistant Professor , Consultant Pediatric surgeon

FRCSI, FRCS(Ed), FRCS (glas), FRCSC,FAAP,FACS.

• The initial treatment of seriously injuredpatients consists of :

• primary survey (ABCDEs)

• resuscitation

• secondary survey

• diagnostic evaluation

• definitive care.

Anatomy of body fluids:

- Total body water ( TBW) constitutes

50 – 70 % ( 42 L) of body weight. It is divided into 2 functional compartments; ECF & ICF.

Chemical composition of body fluid Chemical composition of body fluid compartmentscompartments

Ion  

Cations

Plasma (mmol/L)

ICF (mmol/L)

Na+ 143 9

K+ 5 135

Ca2+ 1,3 <0,8

Mg2+ 0.9 25

AnionsCl-

103 9

   

HCO3- 24 9

HPO42- 0,4 74

Sulphate- 0,4 19

Protein 1,14 64

•haemorrhage causes further reduction in intravenous volume

•fluid from the interstitial space is shifted to the intravascular space (autotransfusion)

• Tissue injury results in SIR, release of mediators leading to increase in vascular permeability and tissue edema.

• A decrease in cardiac output and arterial O2 content leads to decreased O2 delivery

• Fluid resuscitation can increase the interstitial edema, which is caused by the 'reperfusion injury' to the capillary interstitial membrane. This causes a rise in osmotic pressure in the extracellular spaces and glucose is primarily responsible for this. Tissue edema is rarely life-threatening but can decrease oxygenation, delay healing and can lead to subsequent sepsis

Management of ShockManagement of Shock

• Stop external bleeding

• Administer fluid resuscitation– balanced salt solution at 20 ml/kg repeat as

needed

– Packed RBCs at 10 ml/kg

• Surgery if condition remains unstable after

fluid resuscitation

3 3 for 1 Rulefor 1 Rule

a rough guideline for the total amount of crystalloid volume acutely is to replace each ML of blood loss with 3 ML of crystalloid fluid, thus allowing for restitution of plasma volume lost into the interstitial & intracellular space

Initial Fluid TherapyInitial Fluid Therapy

Lactated Ringer is preferredLactated Ringer is preferred

* For adult 1-2 liters bolus

* For child 20ml/kg bolus

with observation of response

The patient's response to this initial resuscitation determines subsequent therapy, 3 response patterns are described:

 1. Rapid: Responds rapidly and remains hemodynamically stable.

 2. Transient - Responds initially then deteriorates as fluids are decreased to maintenance levels.

 3. Non-responsive: Failure to respond either to crystalloids or blood. 

Objectives of Fluid Replacement Objectives of Fluid Replacement

restoring adequate tissue perfusion and oxygen delivery as rapidly as possible

Vascular accessVascular access

• Peripheral IV• Central line• Intraosseus• Venous cutdown

Poiseuille's Law The rate of flow is proportional to the fourth power of the

radius of the catheter and the pressure gradient between the catheter opening and venous system and is inversely related to its length and fluid viscosity.

When to Give Fluid When to Give Fluid

• Became stander of care …..

…… to give as soon as possible.

• External control of hemorrhage should be obtained before restoring circulating volume.

• The administration of IV fluid should not delay transportation to hospital

What should we use?What should we use?

• Lactated Ringers• Normal Saline• colloids • Hypertonic• Blood Substitutes

Infusion of a balanced salt solution is the current standard of care with the

initial bolus, as per Advanced Trauma Life Support guidelines, given "as

rapidly as possible"

crystalloidcrystalloid

• These can be isotonic or hypertonic • the major disadvantage of isotonic

crystalloids is their limited ability to remain within the intravascular space

• LR by the end of a 1 liter infusion expands the intravascular compartment by only 194 ml

• the remaining 80% of fluid is lost to the intersitial space

Colloids Colloids

• A colloid is a fluid, containing particles that are large enough to exert an oncotic pressure across the microvascular membrane

• greater ability to than crystalloids to remain within the intravascular   space and therefore more efficient volume expanders.

• approximately 90% of exogenous albumin can be found in the IV space 2 hrs after administered.

• the serum half life of albumin is about 18 hrs. synthetic colloids such as (hetastarch, hespan) have similar volume expanding abilities

Crystalloids versus colloidsCrystalloids versus colloids

• There are no prospective randomized controlled trials with adequate power to detect a difference in survival as the primary endpoint.

• in comparison with colloid, larger volumes of crystalloid are required to restore intravascular volume.

• Colloids can cause anaphyllactoid reactions and impair coagulation .

OthersOthers

• Albumin

• Hypertonic saline solutions

• Hemoglobin solutions

Blood Transfusion Blood Transfusion

• the best resuscitation fluid

• volume expansion and also transports oxygen

• The major reasons for transfusing blood and blood products in trauma are1. Improvement of oxygen transport

2. restoration of red cell mass

3. correction of bleeding caused by platelet dysfunction

4. correction of bleeding caused by factor deficiencies. 

• Transfusion with1. 'O' Rh negative 2. type specific blood 3. Cross matchblood

• Disadvantages:– cross-matched– Massive transfusion can produce dilutional

coagulopathy, hypocalcemia and hypomagnesemia.

– Blood-borne viral pathogens may be transfused.

Thermal protection.Thermal protection.

• Fluids should be stored at body temperature and blood products should be administered through rapid-warming devices.

• When examination is completed, thepatient should covered with warm blankets or other devices until body temperature returns to normal.

• Hypothermia following a major trauma increase mortality and has a number of adverse effects:

– Oxyhemoglobin dissociation curve is shifted to the left which impairs peripheral oxygen unloading.

– Shivering will compound the lactic acidosis that accompanies hypovolemia.

– Hypothermia increases bleeding by dilutional coagulopathy.

– Hypothermia increases the risk of infection. – Hypothermia increases the risk of cardiac morbid

events

End points of Resuscitation End points of Resuscitation

• Coroner stone of trauma management– Control of bleeding– restoration of circulating blood volume – providing adequate oxygenation at the cellular

level

• No single end point has found to be sufficient by itself

• Patients who have a good response to fluid infusion, i.e., normalization of vital signs, clearing of the sensorium, evidence of good peripheral perfusion (warm fingers and toes with normal capillary refill) are presumed to have adequate perfusion.

• Urine output is a quantitative and relativelyreliable indicator of organ perfusion. Adequate urine output is 0.5 mL/kg/hin an adult, 1 mL/kg/h in a child, and 2 mL/kg/h in an infant less than 1year of age.

• the metabolic acidosis seen in the early phase of the resuscitation of the trauma pt is due to poor tissue perfusion and will reverse with adequate volume has been restored

• BP, HR, urine output, mental status, pulse oximeter and capnogram are all used but will not reflect the situation at the cellular metabolic level

• aggressive monitors have been shown to improve mortality especially in elderly patients like the

• CVP• pulmonary artery occlusion pressure• cardiac index• oxygen consumption • oxygen delivery • base deficit • Serum lactate • Organ specific monitoring e.g: measuring intra-

mucosal (gastric mucosal) pH

Assumption

Elevating blood pressure is always a good thing

May Be NOTMay Be NOT

Elevating blood pressure in uncontrolled hemorrhage

• Acceleration of hemorrhage

• Mechanical clot disruption

• Dilution of clotting factors

Permissive hypovolemia or Hypotensive resuscitation

RecommendationsRecommendations • when intravenous fluid is indicated in the prehospital

setting, crystalloid solutions should be the routine choice.

• Transfer to hospital should not be delayed by attempts to administer intravenous fluid.

• Fluid therapy should be titrated against response to guard against over resuscitation. Blood pressure targets could be established, that will maintain better systemic perfusion and reduce the risks of causing further hemorrhage (systolic blood pressure of 80 mm Hg is appropriate for tissue perfusion and minimizing hemorrhage).

BURNS

Burn shock is hypovolemic and cellular in nature, and is characterized by

• decreased cardiac output, extracellular fluid and plasma volume

• oliguria.

As with other forms of shock, the primary goal is to restore and preserve tissue perfusion

Referral to Burn Center

* 2nd or 3rd degree burn >10% BSA, pt under 10 or over 50y/o

* 2nd or 3rd degree burn > 20% BSA in other age group

* 2nd or 3rd degree burn of face/eye/ear/hands/feet/genitalia/perineum or major joints

* 3rd degree burn >5% in any age group

* Significant electrical/lightning injury

* Significant chemical burn

* Inhalation injury

Fluid Therapy in 2nd or 3rd Degree Burn

Total amount of first 24 hours:

4 ml of Ringer lactate x BW(kg) x BSA

* give 1/2 in first 8 hrs

* 1/2 in remaining 16 hrs

• Regardless of the resuscitation formula or strategy used, the first 24-48 hours require frequent adjustments.

• The quantity of crystalloid needed is dependent upon the parameters usedto monitor resuscitation.

• Considerably more fluid will be needed, and more edema will result.

In patients with massive burns, young pediatric patients, and burnscomplicated by severe inhalation injury, a combination of fluids can be usedto achieve the desired goal of tissue perfusion while minimizing edema. Inthese patients, the regimen of modified hypertonic (lactated Ringer's + 50meq NaHCO3) saline fluid containing 180 meq Na/L is used for the first 8 h.

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