TRAUMA AND ATLS FOR EXAMINITION MD/ DA/ DNB

Department of cardiac anesthesia IPGMER KOLKATA

Dr.Sandeep Kumar Kar. Dr.Chaitali Sen. Professor Anupam goswami.

Polytrauma is defined as a clinical state followed by injury to the body with profound physiometabolic changes involving multysystem. Polytrauma patients are these who sustain any one of the following combination. 2 major system injuries + one major limb injury. 1 major system + 2 major skeletal injuries Instable # pelvis with associated visceral injury. 1 major system injury + 1 open grade III skeletal injury.

INTRODUCTION:
Trauma is epidemic in the modern world and has been the leading cause of mortality with increasing number of fast moving vehicular traffic, there has been an increasing incidence of polytrauma. Most of these trauma's involve more than one system such as involving head injury and neck with chest, abdomen or orthopaedic injuries. Most of these injuries are caused by so called acceleration - deceleration injuries. Unfortunately the victims of trauma are often young people, in their best productive years. Apart from the vehicular accidents, polytrauma is often the result of falls, riots, industrial accidents, fire arms and ballistics and others. Trauma challenges the anaesthesiologist with additional responsibilities and reminds us of our duties as a physician. It is a science of resuscitation amenesia and anaesthesia. Increased number of vehicles, increased mass movement, alcohol and drug abuse have increased the risk of serious injury. BODY RESPONSE TO TRAUMA: Whenever there is injury or insult to the body, it tries to maintain a normal homeostasis inspite of the increased metabolic demand by various mechanisms. The hemoendocrine response to hypovolemia results in activation of the sympathetic nervous system with the release of epinephrine and nor epinephrine. The endocrine response is the release of multiple hormones from the hypothalamic pituitary adrenal axis which augment the sympathetic response. The overall effects include vasoconstriction, sodium retention, insulin resistance, gluconeogenesis and lipolysis. Local endothelial injury can lead to activation of inflammation and coaglation at the site of injury which is essential for prevention of infection and' for eventual healing and repair.

TRAUMA TEAM:
It consists of Anaesthesiologist (Team leader) Trauma surgeon Physician www.kakinadaedu.in 1

 Radiologist Nurses and helpers. The anaesthesiologist plays potential roles in the case of a trauma patient as A trauma team member Trauma team leader An anaesthesiologist Critical care physician Pain relief physician Pre-hospital care physician Critical care transport physician Diasaster planning consultant The anaesthesiologist is primarily concerned with rpeserving CNS function, maintaining adequate respiratory gas exchange and achieving circulatory homeostasis. Role of trauma team leader In a multiple casualty disasters identification of victims needing prompt medical attention and those who can wait is performed by the first aiders. Prioritization of victims are done by color code tag. Red require immediate stabilization care and includes victims with - Shock status from any cause - Respiratory distress. - Head injury with unequal pupils - Major external bleeding. Yellow requires close monitoring, care can be some what delayed. This category includes cictims with: - Risk of shock - Compound fractures - Femur, pelvic fractures - Severe burns. - Unconscious, head injury. ll these victims will receive I.V. line, close monitoring for any complication and will receive treatment as soon as passable. Green requires delayed or no treatment - Includes victims with minor fractures minor wounds and burns - These patients after-,receiving dressing and /or splinting will be attended at the end. Black: for patients who are brought dead. Death from trauma has a trimodal distribution (SHORT NOTE. VERY VERY IMPORTANT) I) Peak (non-salvageable): Death occurs within seconds to minutes as a result of www.kakinadaedu.in 2

major injuries to heart, brainstem, aorta and large vessels. The primary prevention is essential in avoiding death. II) Peak (Salvageable): Death occurs within, minutes to hours, due to subdural or epidural hematoma, hemo-pneumothorax, splenic laceration and major fractures. "Golden hour" is the first hour which begins when the victim is injured and not when the medial personnel arrive at the scene. The concept of golden hour was introduced by cowley indicating that these first 60 min were crucial to saving the patients life. This is the period where visceral injury or sever fractures can cause continuing hemorrhage that eventually result in hypovoluemia shock. During this window of opportunity, appropriate treatment can save a life and reduce morbidity. Platinum 10 minutes is the first 10 minutes of pre hospital care given to the patient at the site of Injury. Patients in second peak are amenably salvageable if they are rapidly assessed and the process of resuscitation started at the. earliest. III) Peak: Death occurs from day to weeks due to sepsis, multiple organ system failure, etc. in the high dependency areas like ICU's. Improvement In the initial management will bring down the mortality rate in this group. Advanced trauma life support (ATLS) : The advanced trauma life support manual developed by the committee on trauma of the American college of surgeons (ACS) are designated to Identify and correct the most-life threatening problems first. It has five sequential components. I) Over view a. Perform visual scan of patent for obvious injuries b. Obtain history from prehospital personnel and patient (if able). II) Primary survey (ascertain "AI15CDEs") a. Airway maintenance (with cervical spine control) i. Look for chest wall movements, retraction, and nasal flaring. ii. Listen for breath sounds, stridor; and obstructed ventilation. iii. Feel for air movement. b. Breathing (give supplemental oxygen) i. Determine whether ventilation is adequate ii. Inspect chest to exclude open pneumothorax, or flail segment. iii. Auscultation for bilateral breath sounds. iv. Provide assisted ventilation for ventilatory failure. c. Circulation (establish venous access) i. Check peripheral pulses, capillary refill, and blood pressure ii. Obtain electrocardiogram iii. Grade shock according to vital signs iv. Correct hypovolemia and obtain blood samples. d. Disability to determine neurological status) i. Evaluate central function A: Alert V: Responds to vocal stimulus P: Responds to painful stimulus U.: Unresponsive www.kakinadaedu.in 3

ii. Evaluate pupil response to light. e. Expose patient for complete examination. III) Resuscitation phase IV) Secondary survey V) Definitive care phase.

I) OVERVIEW:
Initial evaluation: The orderly progression of history, physician examination, diagnosis and treatment must often be abandoned with trauma patients because resuscitation has priority over diagnosis. Rapid overview: The initial moments following the patients arrival In the emergency room are devoted to obtaining the most basic information about the overall condition of the patient and injuries injuries by visual scan. History: - Accident History - patient history Accident History: Information about the accident may help in evaluating the pattern and severity of injury. It can be obtained form the patient (if possible), trauma team members or from the patients friends or relatives. Relevant questions should be asked In different types of trauma like. Motor vehicle accident ? about type of Impact, speed and size of the vehicle, location of the victim In the car etc. Information should also be obtained about pre-hospital resuscitation and the condition of the victim on the scene and during transport. Patient history: A brief and organized approach to obtaining the trauma patient's history' is characterized by the acronym AMPLE. A : Known allergies M : Medications used by the patient P : Past illness or surgery L : Timing and content of last meal E : Events preceding the accident.

II) PRIMARY SURVEY:

Primary survey aims at basic physiologic support and resuscitation. The objective of primary survey Is to Identify life and limb threatening injuries and it consists of the ABCDE. A Airway with cervical spine protection B Breathing and ventilation C Circulation with haemorrhage control D Disability / neurological status E Exposure / environmental control. Airway with cervical spine protection: Patency of the airway is assessed first, by looking for foreign bodies and facial, mandibular fractures or tracheal/ laryngeal injures that may result in airway obstruction. www.kakinadaedu.in 4

 Suspect a cervical spine injur y in polytrauma especially with an altered level of consciousness or evidence of Injury above the level of the clavicle. Manual in line traction is provided while securing the airway. Noisy breathing suggest an obstruction. If cervical spine injury is ruled out, a triple airway maneuver consisting of head tilt, chin lift and jaw thrust should be performed with suctioning of the mouth to clear the airway. In unconscious patients or with cervical spine injury only jaw thrush must be done and an ore-pharyngeal airway Is required with C-spine protection. A cuffed endotracheal tube which ensures adequate ventilation and protects against aspiration is the definitive airway. Airway access can be oral/nasal or surgical. Once airway is cleared and secured, 100% 02 at a flow rate of 15 liters/min can be delivered. Neck: It is quickly examined for wounds, tracheal position, venous distension, surgical emphysema and crepitus. Cervical spine should be stabilized with semi rigid collar, sand bags and tape. Table 3. grading system correlating the severity of upper Respiratory obstruction and the resulting sings and symptoms Stage of obstruction Signs and symptoms I No stridor at rest Mild or potential obstruction Cough hoarseness II Stridor on slight exertion Moderate obstruction Rib retraction on inspiration dilation of alae nasi on inspiration use of accessory respiratory muscles Indrawing of cervical soft tissues Tugging of jaw and trachea on inspiration dyspnea III Stridor at rest Severe obstruction apprehension Restlessness Sweating Pallor increase in pulse rate and blood pressure exaggerated excursion of neck veins IV Slowed respiration Very severe obstruction Hypotension Cyanosis Impaired consciousness Indications for a definitive airway: Airway Obstructed airway Inadequate gag reflex Breathing Inadequate breathing, Oz saturation less than 90%. www.kakinadaedu.in 5

Circulation Inadequate circulation, systolic BP < 75mmHg despite adequate fluid resuscitation. Disability Coma, Glasgow coma scale <8/15. Environment: Hypothermia, core temp <33C. Breathing and ventilation: If the patient cannot maintain adequate tissue oxygenation n spite adequate quantities of O2 then artificial ventilation must be instituted. Some of the common causes of Inadequate ventilation. Bilateral Unilateral 1. Obstruction of` upper respiratory tract 3. Intubation of right main bronchus 2. Leak between face and mask 4. Pneumothorax 5. Hemothroax 6. Foreign body in main bronchi 7. Lung contusion Immediate life threatening thorasic conditions must be noted and treated immediately. 1. Airway obstruction - must be relieved. 2. Tension pneumothorax - needle thoraco-centesis in second intercostals space using a 14 guage needle. 3. Open chest wound - must be dressed. 4. Massive hemothorax - chest drain in 5th intercostals space anterior to mid axillary line. 5. Flail chest - Internal pneumatic fixation by intubation and positive pressure ventilation / operative fixation of ribs. Circulation and haemorrhage control: The aim is to evaluate the patients hemodynamic state while controlling hemorrhage and restoring adequate perfusion. Shock can be classified as follows depending upon the blood loss Class I : < 15% Class II : 15-30% Class III : 30-40% Class IV : > 40% Watch for signs of shock: respiratory rate heart rate capillary refill time Skin pallor Cold and clammy extremities blood pressure pulse pressure urine output level of consciousness. Two wide bore 14-16G peripheral lines should be started immediately. Pressure over bleeding site must be applied. www.kakinadaedu.in 6

 Torinquet should not be used except in traumatic amputation of an extremity. 2 liters of R.L (Hartmans solution) or 1 liter of colloid bolus can be rushed and the patient condition is re-assessed. Rapid response < 20% blood loss. Trnsient response: > 20% blood loss/active bleeding (+) / need blood transfusion and surgery. No response: > 40% blood loss/bleeding is more than transfused blood/needs immediate surgery. DIASABILITY (Neurologic evaluation): It refers to the initial assessment of neurologic function. Rapid neurological evaluation using 2 level protocol to assess the level of consciousness should be done An alteredlevel of consciousness Indicates the need for immediate reevaluation of the patients oxygenation ventilation and perfusion status. Two level initial evaluation of consciousness: Level 1 AVPU system A-Alert V-Responds to verbal stimuli P-Responds to painful stimuli U-Unresponsive Level 2 Glassgow coma scale (GCS) Eye opening (E) spontaneous already open and blinking 4 To speech 3 to pain 2 None 1 Verbal response (V) Oriented 5 Answers but confused 4

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inappropriate, but recognizable words 3 incomprehensible sounds 2 None 1 Best motor response (M) Obeys verbal commands 6 Localizes painful stimulus 5 Withdraws from painful stimulus 4 decorticate posturing (upper extremity flexion) 3 decerebrate posturing (upper extremity extension) 2 No movement 1 Exposure: It involves completely undressing the patient for a through examination, assessment & intervention. Technique for removal of clothing to minimize patient movement. Clothing should be cut along the anterior midline of the garments. Prevent hypothermia by covering the patient with warm blankets after examination.

RESUSCITATION:
Aggressive resuscitation and management of life threatening injuries, as they are identified, are essential to maximize patient survival. Adequacy of resuscitation is monitored by. Airway - Pulse oxymetry/capnography. Breathing - Respiratory rate/capnography/ABG. Circulation - Assessing perfusion by blood pressure/pulse/temperature/central venous pressure & urine out put. Disability - Pupils/AVPU scale/Glasgow coma scale. Environment - Cone temperature.

SECONDARY SURVEY:
Secondary survey begins after the primary survey is completed and while resuscitation is in progress. www.kakinadaedu.in 8

Secondary survey involves the detailed head to toe evaluation of the patient, often described as "tubes & fingers in every orifice. The secondary survey should result in a complete list of injuries that allows the formulation of a management plan. 1. A detailed medical history. 2. Head to toe evaluation. 3. Complete neurological examination. 4. Sonography for trauma/Diagnostic peritoneal lavage. 5. Radiological evaluation 6. Laboratory studies

MEDICAL HISTORY:
A detailed history for following is taken. A - Allergies M - Medication P - Past medical history/ pregnancy L - Last meal E - Event leading to injury & environment Head to toe evaluation: Head: Entire scalp and head should be examined for lacer ations, contusions and evidence of fractures. If scalp laceration is present, bleeding should be controlled immediately since scalp is a highly vascular structure. Bleeding can be stopped by applying direct pressure or by suturing. Look for evidence of bleeding or CSF leak from nose and ears to rule out cribriform plate damage and basal skull fracture. Eyes: Pupil size and reactivity are tested, and visual acuity is assessed if possible. Look for any other evidences of Injury. Contact lenses must be removed before orbital edema develops. Mouth Look for lacerations which may be bleeding. Any vomitus or broken tooth should be removed Immediately to maintain a patent airway. Look for any evidence of mandibular fracture which may cause airway obstruction. Cervical spine should always be reinforced with sand bags, semirigid collar and tape during the airway monoeuvers.

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Cervical spine and neck: Patients with maxillofacial of head trauma should be presumed to have an unstable cervical spine injury and the neck should be immobilized until all aspects of the cervical spine have been adequately studied and an injury has been excluded. The absence of neurological deficit does not exclude injury to cervical spine. Cervical spine tenderness, subcutaneous emphysema, tracheal deviation and laryngeal injuries must be evaluated because early intubation may be required before swelling compromises the airway. Thorax: Examination of thorax is done by reviewing the findings of the primary survey. Auscultate for breath sounds high on the anterior chest wall for pneumothorax and posterior bases for haemothorax. If intubated check endotracheal tube placement. Intercostal drainage tubes may be necessary in the presence of pneumo/ haemothorax. Abdomen: A thorough examination is done by inspection, palpation, percussion and auscultation. Exposed bowel is covered with warm saline soaked swabs to avoid hypothermia and fluid loss. Focused abdominal sonography for trauma and diagnostic peritoneal lavage help us to assess the type and severity of injury and plan further management. Look for urethral, renal, liver & splenic injuries. Rectal examination - Sphincter tone; Rectal damage; Pelvic fractures; Prostate position. Extremities: Long bone fractures can cause considerable blood loss. Fractures of femur or humerus can cause 1.5 to 2 litres of blood loss, Signs of spinal cord injury Hypotension and bradycardia The compensatory mechanism in patients with hypovolemic shock like tachycardia and peripheral vasoconstriction are absent in patients with, spinal' cord injuries. This is because of loss of sympathetic tone as well as disruption of cardio accelerator fibres. Table 7. NEUROLOGIC EVALUATION OF SPINAL CORD INJURY: Function Clinical finding Injured spinal cord element Autonomic Loss of bladder control Prasympathetic pathways Loss of rectal control Priapism Reflex Areflexia initially Reflex arcs within the Hyperreflexia after a few weeks spinal cord Sensory Loss of superficial pain and Spinothalamic tract temperature on the side opposite the injury Posterior columns, www.kakinadaedu.in 10

Loss of position sense of the fingers and toes transmitting on the side of injury proprioceptive impulses Loss of vibration sense on the side of injury Posterior colums Motor Loss of voluntary muscle contractions on the Corticospinal tract side of injury Loss of involuntary response of pain on the Corticospinal tract side of injury Definitive care: Successful implementation of the ATLS protocols should result in the rapid, accurate, and effective assessment, management, and continuing care to the trauma patient. Completion of the previous phases should provide information to plan definitive management, which may be surgical or non surgical or involve transferring the patient. Trauma scoring: POSTED JUST BEFORE

FLUID RESUSCITATION IN POLYTRAUMA:

Circulatory shock is the most common complication of polytraunla that requires treatment during the initial phase. Prolongation of shock, even for a brief period, is likely to contribute to the development of organ failure and death during the later stages of care. Hemorrhage is the most common etiology of traumatic shock contributing to inadequate perfusion. Prompt recognition of the mechanism of hypotension is essential so that appro priate treatment can be promptly instituted. Fluids are effective initially in all types of shock, they gradually lose their effectiveness if definitive treatment of any non hemorrhaggc cause is' delayed. The clinical signs of hemorrhage are classified into four categories depending on the response to the volume lost. Advanced trauma life support classification of hemorrhagic shock Class I Class II Class III Class IV Blood loss (Ml) Up to 750 750-1500 1500-2000 = 2000 Blood loss (% up to 15% 15% - 30% 30% - 40% = 40% blood volume) Pulse rate < 100 > 100 > 120 = 140 Blood pressure Normal Normal Decreased Decreased Pulse pressure Normal Decreased Decreased Decreased (mm Hg) Nomal or Posivitive Positive Positive Capillary refill increased test Normal Respiratory 14-20 20-30 30-40 > 35 rate = 30 20-30 5-15 Negligible Urine output www.kakinadaedu.in 11

(mL/hr) CNS mental Slightly Midly anxious Anxious and Confused, status confused lethargic Fluid Crastalloid Crystalloid Crystalloid Crystalloid replacement blood blood (3.1 rule) Manifestations of the adequacies of 3 regional micro circulations are observable in the early assessment of trauma patients. Poor blood flow To skin is immediately evident as cool, pale, sweating peripheries. To brain is manifested as altered consciousness (anxiety confusion, and restlessness). To kidneys is observable as oliguria.

ROUTES FOR FLUID ADMINISTRATION

1) Peripheral intravenous route: One or more large bore (16-gauge or larger) peripheral intravenous catheters for the administered of fluids and blood should be placed as quickly as possible In the management of the trauma patient. o First choice for cannulatlon is a vein that is visible. o Second choice is the external jugular vein. Third choice, although invisible, is the femoral vein. The pulsations of, which are palpable during spontaneous circulation in shock and 'during cardiac compression. A larger cannula (8.5 to 12 French gauge) can be placed by means of the Seldlnger technique in to the femoral vein. The last choice in adults for peripheral venous cannulatlon is a rapid venous cut down. The last choice for cannulation in children is the itnrasseous route. Which is ideally done with an 18- gauge, 4cm jamshedi bone marrow needle. # 14- #8 cook interaosseous infusion needle is percutaneously inserted Into the flat portion of the proximal tibia just below, and medial to, the tibial tuberosity the depth of the needle insertion should be planned before placement. If it advanced too far, the needle will penetrate the posterior cortex and will not allow Infusion. Aspiration of bone marrow identifies adequate needle position. Fluids may be infused, by the intraosseous route, at rate up to 40ml/min (using 300 mmHg pressure). Needle is placed 2 cm below the tibial tuberosity fro m an anterior approach and directed towards the feet to avoid the tibal growth plate. 2) Central venous route: The superior vena cava is the preferred vessel for central venous catheterization. Many consider the right internal jugular vein the preferr ed approach to superior vena cava catheterization. www.kakinadaedu.in 12

 Superior vena cava is preferred because a catheter in the superior venacava is less dysrhythmogenlc than one in the right atrium or pulmonary artery. Air embolism must be avoided whenever the catheter is opened to the atmosphere and particularly in hypovolemic patient by slightly lowering the head end, the conscious patients should be asked to hold the breath, where as the un conscious patient should receive positive pressure ventilation. Catheterization through the subclavian vein remains a last choice because it is associated with a slightly higher incidence of lung puncture leading to pneumothorax. Catheter location in relation to the site of injury Location of the injury must be considered when choosing a site for venous access. Avoid venous access in injured limbs In patients with injuries below the diaphragm at least one IV should.be, placed In a tibutary of superior vena cava because vascular disruption of the inferior vena cava may be present. Infusion strategies: Rapid volume infusion accompanied by packed red blood cells continues to be the mainstay. During emergency resuscitation and post resuscitative life support, Intravenous fluids should be administered with the following objectives. To restore normal circulating blood volume immediately after fluid losses, using combinations of electrolyte solutions, colloids, and solutions containing red blood cells. Rapid, massive infusion of isotonic salt or colloid solutions can be life-saving, particularly in patients with severe external or, internal blood loss. To restore and maintain the extracellular extravascular volume, predominantly with crystalloids, since this internal redistribution is related more to the degree of tissue trauma and ischemia than to blood loss per se. To keep an intravenous route open for drug administration and also provide basic hydration. This may be accomplished by a continuous infusion of 5% dextrose in 0.75% to 0.5% sodium chloride, 20 to 25 ml/kg/24 hr for adults and children, and 100ml/kg/24 hr for infants. Hyperglycemla caused by massive infusion of dextrose containing fluids should be avoided, since it may worsen, cerebral edema and neurologic outcome. To adjust this therapy promptly for increased or decreased diuresis, keeping urine flow greater than 0.5ml/kg/hr. To change intravenous fluids to achieve normal serum electrolyte concentrations, osmolality, and colloid osmotic pressure, serum albumin (3 to 5g/dl); hematocrit (30% to 40%); and serum glucose (100 to 200mg/dl). Total amount and rate of intravenous infusion depend on the total volume and rate of estimated blood loss and the type of fluid selected.

FLUID RESUSCITATION IN CHILDREN:

Most significant pathophysiologic defect in traumatized children is hemorrhagic shock. Earliest manifestations of shock are www.kakinadaedu.in 13

o Delayed capillary refill o Mottled skin Cool extremities Tachcardia In children systolic and diastolic blood pressure remains relatively constant because of peripheral vasoconstriction and may be maintained until there is a 30% to 40% loss of circulating blood volume and therefore the hypovolernic patients may have a narrow pulse pressure. o Arterial pH is a good indicator of circulatory status in children. If pH is low, in the presence of normal or low carbondioxide, it should be assumed that circulating blood volume is inadequate, until proven otherwise. If the pH fall's below 7.2 in a child with adequate ventilation, sodium bicarbonate may be added to fluid replacement which can be caliculated by Dose = body Wt In kg x 0.15 mEq x base deficit, given as an IV bolus, followed by reassessment of the pH. For initial fluid resuscitation, Ringer's lactate is administered as a bolus (20ml/kg). If vital signs fail to improve, boluse of RL may be repeated three times. o If, despite the infusion of RL, hypotension or shock continues, either '0' or type specific red blood cells are administered (10ml/kg increments upto 30-40 ml/kg.)

Types of fluids:
All plasma substitutes and electrolyte and colloid solutions produce hypercoagulability by diluting the clotting factors. Crystalloid solutions: Crystalloids are divided into - Isotonic - Hypertonic. Isotonic solutions: There are normal saline and ringer lactate. They freely equilibrate through intravascular and interstitial spaces but do not promote intracellular fluid shifts. o Advantages of these fluids are, less expensive, availability and effective interstitial fluid deficit replacement. Normal saline may cause hypernatre mia and hyperchloremic metabolic acidosis. Hypertonic solutions: 3% and 7.5% hypertonic saline are commonly used. IT restores the blood volume by maintaining a contracted interstitial space. Advantages: www.kakinadaedu.in 14

 Lesser infusion volume. Positive inotrophic effect Direct vasodilatory effect It causes increase in mean arterial pressure and cardiac output followed by peripheral vasodilatation with an increase in renal, mesenteric, total splanchnic and coronary blood flow. Disadvantages: Transient increase in blood pressure and vasodilatation may increase hemorrhage from open blood vessels. Potential for hypernatremia and hyperchloremic metabolic acidosis. 3 for 1 rule Isotonic electrolyte solutions are used for initial resuscitation. o A rough guideline is to replace each ml of blood loss with 3ml of crystalloid fluid, thus allowing restitution of plasma volume lost into interstitial and intracellular space. Crystalloid administration - clinical problems: It reduces viscosity thereby enhancing bleeding from injured vessels. It lowers the hematocrit and dilutes the clotting factors. Resuscitation with large volume of cold crystalloids aggravates hypothermia. Impairment of immure system is seen as a consequence of rapid bolus of crystalloids. COLLOIDS: 1) Hydroxy ethyl starch: It is a branched glucose polymer with variable molecular weight and clearance. Clearance rate is 46% of the dose cleared in 2 days and 64% in 8 days but detectable starch may be present as many as 17 weeks. Recommended dose is 20ml/kg/d as a volume expander and dose in excesses of >20ml/kg results in coagulopaty. It doesn't carry the risk of transmitting Infectious diseases and has the lowest rate of anaphylactold reactions. 2) Albumin: 5% / 25% solution: o Its a major serum protein accounting for 80% of plasma concentration of protein. o Intravascular half life of albumin in 16 hours. Doses in excess of 20ml/kg result in intravascular volume increases by more than the volume infused because the high concentration of protein draws in interstitial water. It presents a risk of dilutional reduction in fibrinogen and other clotting factors. Albumin binds calcium and there by has a negative inotropic effect. extron: Dextron 40 / Dextron 70 Mixtures of glucose polymers of various sizes and molecular weight. www.kakinadaedu.in 15

 Oxygen delivery is improved by Improvement In microcirculatory blood flow distribution resulting from lower blood viscosity. Dextron 70 has a 30% intravascular retention after 24 hours and may reduce the incidence of ARDS. Dextron 40 has a shorter retention time but does, not elevate sedimentation rate and may have a more potent antiplatelet effect. Dextrin 40 should, however, be given only after urine flow has been restarted with infusion of electrolyte solution, because it may worsen renal tubular function. Hypertonic saline Dextron (HSD): Hypertonic saline dextran is 7.5% saline solution in 6% dextran 70. HSD provides 12 times the volume expanding capacity of an equal volume of isotonic crystalloid. HSD causes a temporary fluid shift from the interstitial and intracellular space to the Intravascular space. Half life of HSD is 8 hours. HSD preserves regional blood flow and capillary diameter as compared with hypertonic saline solution alone. HSD Improves pulmonary blood flow and renal function. HSD maintains pulmonary artery pressure and pulmonary vascular resistance at baseline values. Main disadvantage of HSD is hypernatremia and acute vasodilatation when infused rapidly, but this is a transient phenomenon. BLOOD PRODUCTS: Blood component therapy: Banked blood or packed red blood cells should be used to sustain the hematocrit at 25% to 30%. The main purpose of transfusing blood is to restore the oxygen carrying capacity of the intra vascular volume. Pasteurized plasma preparation like 5% plasma protein fraction are safe but, may occasionally contain vasodilator substances. Fresh - frozen plasma or cryoprecipitate is indicated for replacement of isolated factor deficiencies, reversal of warfarin effect, and massive blood transfusion. Blood should be warmed to near body temperature. Packed red blood cell solutions, because of their high hematocrit value, should be diluted with isotonic saline solution in the bag to increase the infusion flow rate and to decrease hemolysis. Undiluated packed red blood cells should be infused slowly and judicious diuresis are recommended in cases of anemia associated with heart failure. FLUID RESUSCITATION FOR TRAUMA PATIENTS IN 21ST CENTURY. Oxygen therapeutic agents: Ideal blood substitute would be disease free and have a long life universal ABO www.kakinadaedu.in 16

compatibility and a similar oxygen carrying capacity.

SHORT AND LONG TERM GOALS FOR RESUSCITATION

Parameter Short term Long term 1. Systolic blood pressure 80-100 mmHg > 100 mgHg 2. Heart rate < 120 bpm < 100bpm 3. Arterial pH > 7.20 Normal 4. Hematocrit > 25% > 20% 5. Serum Lactate < 6 Normal 6. Urine output > 1.5 m/kg/hr 7. Pulmonary artery Not usually > 3 ml/kg/h occlusion pressure measured > 18mm Hg 8. Cardiac Index > 3L/min/m2 9. Oxygen delivery (DO ) > 600 ml/min/m2 2 10. oxygen consumption (VO ) > 150 ml/min/m2 2 11. Mixed Venous Saturation (SVO ) > 70% 2 Intra venous fluid replacement in hemorrhagic shock Class I : 2.5 L RL (or) 1 L Polygelation Class II : 1.5L RL + 1 L Polygelation Class III : 1 L RL + 0.5 L Polygelation + 1-1.5 L while blood (Or) 0.1 1.5 L equal volume of concentrated Red cells + polygelatin Class IV : 1 L RL + 1 Polygelatin + 2 L whole blood (or) 2 L equal volume concentrated Red cells and polygelation (or) hetastarch. Responses to fluid resuscitation Rapid response Transient No response Response Vital signs Return to Normal Transient Remain abnormal improvement BP Estimated blood Miniral (10-20%) Moderate and Severe (> 40%) loss ongoing (20-40% Need for more Low High High crystalloids Need for blood Low moderate to high Immediate Blood preparation Type and cross Type specific Emergency blood match release Need for operative Possibly Likely High likely intervention www.kakinadaedu.in 17