Early Fluid Resuscitation in Severe Trauma

It's been a fantastic (and busy) day at the EDTCC headquarters.  A mammoth whiteboard session with EDExam's very own Andy Buck, on a collaborative upcoming project (more to follow), followed by a podcast on Minh Le Cong's (@rfdsdoc) PHARM blog with some of Oz ED's greats - Casey Parker (@broomedocs) of Broomedocs blog, and the vivacious Michelle Johnston (@Eleytherius) from LITFL blog.

Listen to the podcast here.

This podcast was stimulated by a great review article in the BMJ by Tim Harris and Karim Brohi (@karimbrohi) at the Royal London Hospital.

In this article, the key concepts of damage control resuscitation, and fluid resucitation in different settings are explored and outlined. I highly recommend that you get access to the full article. 

"Summary points

• Critically injured trauma patients may have normal cardiovascular and respiratory parameters (pulse, blood pressure, respiratory rate), and no single physiological or metabolic factor accurately identifies all patients in this group

• Initial resuscitation for severely injured patients is based on a strategy of permissive hypovolaemia (hypotension) (that is, fluid resuscitation delivered to increase blood pressure without reaching normotension, aiming for cerebration in the awake patient, or 70-80 mm Hg in penetrating trauma and 90 mm Hg in blunt trauma) and blood product based resuscitation

• This period of hypovolaemia (hypotension) should be kept to a minimum, with rapid transfer to the operating theatre for definitive care

• Crystalloid or colloid based resuscitation in severely injured patients is associated with worse outcome

• Once haemostasis has been achieved, resuscitation targeted to measures of cardiac output or oxygen delivery or use improves outcome

• Tranexamic acid administered intravenously within 3 h of injury improves mortality in patients who are thought to be bleeding"

BMJ 2012; 345 doi: 10.1136/bmj.e5752 (Published 11 September 2012)

Resources

Karim Brohi's (@karimbrohi) lecture on Permissive Hypotension

Broome Docs Massive Transfusion Protocol 

PHARM Podcast 39 - Haemorrhagic shock in remote settings with the Three Resusciteers

EMCrit Blog - Tranexamic Acid (TXA), Crash 2 with Tim Coats.

EMCrit Blog - Podcast 30 - Haemorrhagic Shock Resuscitation with Richard Dutton MD