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Prehospital Trauma Care 3

Prehospital Trauma Care 3

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Published by seigelystic
Fluid resuscitation is a vital treatment in the care of hypotensive trauma patients. Restoration of effective circulating blood volume improves oxygen delivery, thereby diminishing the untoward effects of shock at the cellular and organ level. However, fluid resuscitation, in and of itself, is not a panacea. Whereas restoration of effective circulating blood volume is essential, the method of supplying fluid is more controversial and complicated by several confounding factors. The inability to deliver definitive care in the field, the heterogeneity of patient populations, the variability in mechanism of injury, and the level of infield hemorrhage control make precise study of the topic challenging. Therefore, the debate persists concerning the type, the amount, and the timing of fluid administration. The purpose of this discussion is to provide insight in the use of fluid resuscitation of trauma patients in the prehospital setting.
Fluid resuscitation is a vital treatment in the care of hypotensive trauma patients. Restoration of effective circulating blood volume improves oxygen delivery, thereby diminishing the untoward effects of shock at the cellular and organ level. However, fluid resuscitation, in and of itself, is not a panacea. Whereas restoration of effective circulating blood volume is essential, the method of supplying fluid is more controversial and complicated by several confounding factors. The inability to deliver definitive care in the field, the heterogeneity of patient populations, the variability in mechanism of injury, and the level of infield hemorrhage control make precise study of the topic challenging. Therefore, the debate persists concerning the type, the amount, and the timing of fluid administration. The purpose of this discussion is to provide insight in the use of fluid resuscitation of trauma patients in the prehospital setting.

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Published by: seigelystic on Oct 04, 2012
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PREHOSPITAL TRAUMA CARE 3
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PREHOSPITAL FLUID RESUSCITATION: WHAT TYPE, HOW MUCH AND CONTROVERSIESFluid resuscitation is a vital treatment in the care of hypotensive trauma patients. Restoration of effective circulating blood volume improves oxygen delivery, thereby diminishing the untowardeffects of shock at the cellular and organ level. However, fluid resuscitation, in and of itself, is not apanacea. Whereas restoration of effective circulating blood volume is essential, the method of supplying fluid is more controversial and complicated by several confounding factors. The inability todeliver definitive care in the field, the heterogeneity of patient populations, the variability inmechanism of injury, and the level of infield hemorrhage control make precise study of the topicchallenging. Therefore, the debate persists concerning the type, the amount, and the timing of fluidadministration. The purpose of this discussion is to provide insight in the use of fluid resuscitation of trauma patients in the prehospital setting.
EPIDEMIOLOGY 
If trauma is the leading cause of civilian death in Americans aged less than 45 years and the fourthleading cause of death in the United States for all ages, hemorrhagic shock is the primary physiologicdefect leading to death. Volume deficits develop not only as a result of blood loss, but also due todiffuse capillary-endothelial leak and fluid shifts from intravascular to the interstitial space. Thesedeficits, and the attendant hypoperfusion, potentially lead to multiple organ dysfunction, failure,and death.Aggressive fluid administration has been mainstay therapy in trauma patients for over 40 years.Estimates of the numbers of trauma patients in the United Kingdom given prehospital intravenousfluid range from 8.6 to 65 patients per 100,000 population per year. However, for the last 15 years,this practice, especially in the setting of uncontrolled hemorrhage, has been questioned.
CAUSES OF SIGNIFICANT HEMORRHAGE
The causes of hemorrhage vary depending on the mechanism of injury. In blunt trauma, bleedingusually emanates from solid organs such as the spleen and liver, mesenteric blood vessel tears,pelvic and femur fractures, thoracic bleeding from lung lacerations or intercostal vessel bleedingfrom rib fractures or external causes such as scalp lacerations. Uncontained bleeding from aortictransection and cardiac rupture usually leads to exsanguination at the scene. When the woundingmechanism is secondary to penetrating trauma, uncontrolled major vascular injury usually is thesource of the hemorrhage.
DIAGNOSIS/ASSESSMENT
In the prehospital setting, emergency medical technicians perform an immediate assessment of thetrauma victim in the form of a primary and secondary survey. This assessment includes an evaluationof the patient for life-threatening conditions that need to be promptly addressed. The patency of theairway is initially evaluated. This is followed by auscultation of breath sounds assessing forpneumothoraces or hemothoraces. Attention is then turned to the circulation. Central andperipheral pulses are assessed. Obvious sources of external blee
ding are controlled. The patient’sblood pressure is measured. Because definitive care cannot be rendered at the scene, a “scoop andrun” rather than “stay and stabilize” philosophy should be evoked. Attempts at intravascular
cannulation should not delay transfer to the trauma center.
 
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PREHOSPITAL TRAUMA CARE 3
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 CLASSES OF HEMORRHAGIC SHOCK
Hemorrhage is the most common cause of shock in the injured patient. Shock is defined as thepresence of inadequate oxygen for normal aerobic metabolism; aerobic metabolism occurs leadingto lactic acidosis. If this process continues, cellular membranes lose their integrity leading to cellularswelling, progressive cellular damage, and ultimately, cellular death.Hemorrhage, an acute loss of circulating blood volume, is classified based on the percentage of blood volume loss. Specific hemodynamic, respiratory, central nervous system, urinary, andintegumentary changes occur given the degree of shock (Table I). Whereas class I hemorrhage isassociated with minimal clinical symptoms and requires little, if any, volume replacement, class IVhemorrhage is immediately life-threatening, necessitates blood transfusion, and usually calls forsurgical intervention to halt on going bleeding.
MANAGEMENTAccess
The basic management principles to follow in hemorrhagic shock are to stop the bleeding andreplace the volume loss. Establishing a patent airway with adequate ventilator exchange andoxygenation is the first priority. Supplemental oxygen is supplied while external bleeding iscontrolled. Two large-caliber (minimum of 16-gauge) peripheral intravenous catheters are inserted,preferably in the antecubital veins. Intravenous access should not delay transport of the patient tothe trauma center.
Types of Fluid
CrystalloidsA crystalloid is a solution of small non-ionic or ionic particles. They are freely permeable to thevascular membrane and are distributed mainly in the interstitial space. As such, only one-third of thevolume of crystalloid infused expands the intravascular space. This accounts for the need to provideat least three times more volume of crystalloid than the volume of blood lost. Because of decreasedcolloid osmotic pressure secondary to decreased serum protein concentration from hemorrhage,capillary leaks, and crystalloid replacement, this ratio of volume of crystalloid infused to bloodvolume lost may even approach 7-10:1.Depletion of both the interstitial fluid volume and the intravascular space following severe injurymay be a reason to use crystalloids for fluid resuscitation, which restore volume to both spaces.Animal and human studies demonstrating improved survival from shock when utilizing isotonic fluid
 
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and blood versus blood transfusion alone support this view. Other advantages of crystalloid use inprehospital fluid resuscitation include its negligible cost in comparison to other resuscitative fluids,immediate availability, and long-term storage capacity.Given the predilection of crystalloid to primarily fill the interstitial space, tissue edema is commonand may have deleterious effects. In head-injured patients, increased brain edema may adverselyaffect outcome. Gas exchange may be impaired secondary to pulmonary edema. Endothelial and redcell edema impair microcirculation and tissue oxygen exchange, potentially contributing to multipleorgan dysfunction.According to Advanced Trauma Life Support (ATLS) guidelines, fluid resuscitation of the traumapatient begins with a 2-
L bolus of crystalloid, usually lactated Ringer’s (LR)
solution. LR is an isotonicfluid that contains L-lactate and D-lactate in a 50:50 mixture. The L-lactate is metabolized in the liverto bicarbonate, thereby providing additional buffer. Although the D-lactate isomer is thought to be acause of acidosis, studies have shown that resuscitation with LR does not lead to increased lacticacid levels. However, normal saline (NS), another isotonic crystalloid, can induce a hyperchloremicacidosis when given in large volumes because of its concentration of chloride ions (154 mEq/L).Healey et al., suggest, in their animal model of massive hemorrhage, increased survival rate inanimals resuscitated with LR and blood relative to those animals that received NS and blood. Thisdifference was thought to be secondary to the profound acidosis occurring in the NS/blood group.Because LR has a lower osmolality than plasma (273 mOsm/l vs. 285-295 mOsm/l), large volumes of LR can reduce serum osmolality and contribute to cerebral edema. For this reason, NS may be thepreferred resuscitative fluid in head-injured patients.Hypertonic sodium chloride (HS) in concentrations ranging from 3% to 7.5% has been used for thetreatment of hypovolemic shock. Because of its elevated osmolality, (2400 mOsm/l in 7.5%), HSproduces an increase in intravascular volume that far exceeds the improved myocardial contractility,decreased systemic and pulmonary vascular resistance, mobilization of tissue edema into the bloodcompartment, and reduction in venous capacitance. These effects are transient, however, so HS hasbeen mixed with colloids (dextran or hydroxyethyl starch) to prolong its efficacy, especially whenused for small volume resuscitation.HS decreases intracranial pressure (ICP), primarily in areas of the brain with an intact blood-brainbarrier. Cooper et al., in a double-blind, randomized controlled trial of hypotensive patients withsevere traumatic brain injury, studied the effects of prehospital resuscitation with hypertonic saline
versus Ringer’s lactate on neurological outcome.
These investigators did not find a significantdifference in 3- or 6-month extended Glasgow Outcome Scores between the two groups.

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