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NEPI » Emergency Medicine » Clinical case discussions
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Trauma and Fluid resuscitation
maroju
Guys, here's one more acute scenario. I would very much appreciate your ideas on this. (Trauma surgeons, intensivists, anaesthetists... your opinions too please...)

A patient with polytrauma following a road traffic collision is brought in by ambulance.

Airway: Patent
Sats of 96% (15 ltrs O2 with non re-breathing mask)
RR: 18/min, Good and equal air entry into both lungs
PR: 110, CR<2 secs, MAP=90 mmhg
GCS: 13/15 (E3:V4:M6), PERLA (3mm)

What fluids and how much of it would you give? Would you go entirely by the ATLS principle of hypotension in trauma = hypovolemia, and thus fill him up. Or would you do anything different? Have got any local guidelines? How would you monitor and decide further management?
 
imron
A - Clear
B - Clear
C - Normal (Tachycardia maybe due to pain or irritability)
or
Class 1 or Class 2 shock (Blood loss upto 1500ml may manifest with only tachycardia with normal blood pressure)

I would give the patient a fluid bolus of about 500-1000ml crystalloid while getting a FAST scan as well as the trauma series of xrays. (C-spine, Chest and Pelvis)

I would give a dose of opioid or NSAID IV

I would have a extra look at the cardiac contractility during the FAST scan to rule out any LV dysfunction.

The goal is to ensure that urine output is atleast 0.5ml/kg/hr whether the fluid bolus is required or not.

If all seems well, the normal daily requirement of fluids must be started. Eg:- Normal Saline at 100ml/hr. (Dextrose containing solutions must be avoided in normoglycemic acute brain injured patients.)
 
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maroju
How effective is your assessment of LV dysfunction during FAST going to be? Will it give you the true picture of the actual dysfunction? It could well be masked by the false picture of a myocardium, what with all the 'adrenaline' flying around in this patient who was just involved in a RTA.

I personally donot think that pushing the patient into 'heart-failure' with fluids is a major issue at this point as this can be easily corrected. However underfilling a patient in shock could be (not in the scenario I mentioned) what with all the problems of MOF/ARDS/Cerebral Hypoxia etc.

Any takers for 'permissive hypotension'??
 
imron
I agree with you.

The goal of the FAST is to rule out cardiac tamponade only.
A screening ECHO can be done at the same time if heart failure is suspected. Both can be repeated.

Im FOR permissive hypotension!
Cool
 
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stemlyns
I think most of the acute care is covered. There are few basic things I want to discuss
What
Edited by stemlyns on 10-02-2008 20:44
 
stemlyns
I think most of the acute care is covered. There are few basic things I want to discuss

What
 
stemlyns
What
 
stemlyns
I am trying to post my views in the quick reply and unfortunately only the first sentence is appearing.Wondering if anyone can solve this problem for me.
 
stemlyns
I think most of the acute care is covered. There are few basic things I want to discuss.
What
 
stemlyns
I think most of the acute care is covered. There are few basic things I want to discuss.

What about the c-spine of this patient?????????I would like to see the c-spine secured and will secure it ASAP.

I would like to deal with E perform a good secondary survery and then prooceed to any imaging.

Tachycardia 110 in class2 shock unless proven otherwise and i will treat it with IV crystalloid(preferably RL first bolus of 500ml) and then get a Central line to measure the CVP to be cautious about fluid resuscitation.

I don't buy the point to checking LV dysfucntion when doing FAST scan as i seriously doubt the specificity and sensitivity of this test on the hands of EM physician(no offense......).
I know that we are now moving towards Permissive hypotension and all we are trying to do is avoid any
 
maroju
Stemlyn... looking at the number of posts between 20.39 and 20.54, looks like you want to pip me at the post for 'member of the month award'!!! Sorry, Just joking...

Assume that Airway/C-Spine and Breathing are sorted fully in this patient... wanted to discuss 'C'...

RM
Edited by maroju on 11-02-2008 17:49
 
drsohil
Sorry for picking up an ended topic ..i just joined in y'day and so was going thru the stuff. I appreciate the adequate management of the patient that is already on the way. Apart from the vitals, to discuss the theory of permissive hypotension, I would like to look for the ongoing bleeding status of the patient. And i think, still keeping a MAP in the range of 75mm Hg would suffice during his ambulance transfer and if the patient is going to b shifted to the OT soon in view of bleeding. Why would u want to keep him hypotensive if there's no active bleeding and infact as Imron suggested, keep his urine output going well and keep him on the normotensive side with IV crystalloids and CVP monitoring.
 
maroju
drsohil, the topic certainly is live.... It certainly does give the impression that most of the topics are dying rather prematurely... wonder why?

There are a few issues here:
If there is an obvious source of external bleeding, I wouldn't be that fussed regarding fluid management. The treatment could well be 'plug the hole and fill the tank'!!! Still, there is a definite place for Perm Hypotension...

More importantly, with the above mechanism of injury, the patient may also have internal damage (liver/spleen/mesentery/pelvic organs/renal etc...). I would be vary of any such causes of shock, which would then make me think of definitely invoking 'permissive hypotension' principle. This would possibly minimise bleeding from the micro-vascular bed and also prevent coagulation discrepancies

In this patient however, his GCS is low. Has he got a significant head injury?? If there were to be any other pointers suggestive of this, I would certainly aim for a MAP >90 mmHg (to ensure adequate CPP) and thus avoid cerebral hypoxia...

At the end of the day, I feel it is more a case of balance between the various parameters.

RM
Edited by maroju on 08-03-2008 02:50
 
morpheus
EM echo scans are good to know LV dysfunction.
Remember what most of EM physicians do are just have a visual gauge of the cardiac function than calculate cardiac output actually.
obviously the clinical scenario would define your likelihood of LV dysfunction also...as in a young patient... hmmm not really expecting LV dysfunction.... old patient... well ya maybe.
And even with all the adrenaline flying in ... if the patient has a background LV dysfunction you would see it on the ECHO scan.
the parasternal long axis view would give you enough information about the cardiac function...and you dont have to be a genious to do it.
so i would still go ahead and image the heart in the PLAX view along with the FAST scan... and judge for myself if theres a cardiac dysfunction or not.
Urine output as a monitor... bingo.
And leave footprints in the sands of time.......
 
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