Background
Hypovolemic shock in trauma victims is a life-threatening condition. In the prehospital environment, EMS providers treat hypovolemic shock by attempting to control hemorrhage and by providing fluid resuscitation with crystalloid solutions. It has long been debated which crystalloid solution provides the ideal fluid resuscitation for victims of traumatic hypovolemic shock; whether it be solutions with similar concentration to human blood (isotonic solutions), or whether fluids should be of higher crystalloid concentration (hypertonic solutions). This report will review the current data on hypertonic versus near isotonic fluid resuscitation for victims of traumatic hypovolemic shock. The main source for this report is a Cochrane Review by Bunn, Roberts, Tasker, and Daksha, 2004.
Issues In Trauma Fluid Resuscitation
Early Aggressive Fluid Resuscitation
According to the National Association of EMS Physicians, older resuscitation outcomes used to call for aggressive fluid resuscitation, typically, 2L IV wide open. More recent studies have found that excessive fluid administration in the prehospital setting can lead to poorer patient outcomes (National Association of EMS Physicians). A prospective trial conducted by Bickell et al. (1994), comparing delayed and immediate fluid resuscitation in 598 patients with penetrating torso injuries and prehospital systolic blood pressures less than 90 mm HG, found that delay of aggressive fluid resuscitation until surgical interventions were available improved patient outcome.
Hypotensive Fluid Resuscitation
An alternative to aggressive fluid resuscitation is hypotensive fluid resuscitation. A 2011 study by Morrison et al., looking at the clinical outcomes of the first 90 patie...
... middle of paper ...
...2007). Colloids versus crystalloids for fluid resuscitation in critically ill patients (Cochrane Review). Cochrane Database of Systematic Reviews, Issue 4. [Art. No.: CD000567. DOI: 10.1002/14651858.CD000567.pub3]
Shackford S, Sise M, Fridlund P, Rowley W, Peters R, Virgilio R, & Brimm J. (1983). Hypertonic sodium lactate versus lactated ringers solution for intravenous fluid therapy in operations on the abdominal aorta. Surgery, 94 (1), 41-51.
Shenkin H, Bezier H, & Bouzarth W. (1976). Restricted fluid intake: rational management of the neurosurgical patient. Journal of Neurosurgery, 45 (4), 432–36.
Simma B, Burga R, Falk M, Sacher P, & Fanconi S. (1998) A prospective, randomized, and controlled study of fluid management in children with severe head injury: lactated ringer’s solution versus hypertonic saline. Critical Care Medicine, 26(7), 1265–70.
Inadvertent perioperative hypothermia is a common anesthesia-related complication with reported prevalence ranging from 50% to 90%.(ref 3,4 of 4) The clinical consequences of perioperative hypothermia include tripling the risk of morbid myocardial outcomes and surgical wound infections, increased blood loss and transfusion requirements, and prolonged recovery and hospitalization.(ref 5)
Hypovolemic shock specifically disrupts the cardiovascular system from a significant loss of blood volume that causes blood pressure to deplete and oxygen delivery to cells to slow. A victim entering into hypovolemic shock will experience three sequential stages as the body attempts to maintain homeostasis. These stages are named compensated, decompensated, and irreversible (Wang
At this point, the sepsis bundle order set will be initiated. Within one hour the physician will perform an assessment, laboratory will draw labs and blood cultures, the assigned nurse will initiate fluid resuscitation, and broad spectrum antibiotics will be administered after the cultures are collected. Figure 1 provides a detailed summary of tasks to be completed within the first hour of SIRS indicator identification. Within three hours, fluid resuscitation will be completed, lactate levels are remeasured, and the assigned nurse documents volume status. Within six hours, vasopressors are initiated if hypotension is not responding to initial fluid resuscitation, and hydrocortisone is administered if indicated. A “Gold Alert” was required for the case patient as evidenced by elevated temperature of 38.3oC and white blood cell count of 23,200
Tzong-Jin, W., & Kuo-Inn, T. (1996). Transfusion-Related acute lung injury treated with surfactant in a neonate. European Journal of Pediatrics. 155. (7). 589-591.
Once the paramedics retrieve Marc, he will have a high concentration of salt in his blood and fluids. This means that the paramedics would treat him with the half normal saline. This is the solution with the lowest percentage of solutes (0.45% NaCl).this will increase his concentration of water throughout this body and will return his cells to their normal size. However, if the paramedics were to keep him on the half normal saline for too long, his water concentration would be too high and his solute concentration would become too low. This would mean that the paramedics would then need to switch Marc to the normal isotonic saline solution (0.9% NaCl). This would balance out both the concentration of water and solutes so that they are now equal. This would set his balance and homeostasis back to normal, thereby helping his recovery. (Johnson
ECMO has an established history of being used as a pediatric modality with critically ill patients as a last life-saving effort. Yet, there still is controv...
normal saline, lactated Ringer solution, etc), volume expanders (e.g. albumin and others), antibiotics (e.g. cefotaxime, metronidazole, ciprofloxacin, cefepime, etc), and corticosteroids (e.g. hydrocortisone, dexamethasone, etc).Medications and surgery are often the most effective and most definitive treatments that a doctor or certified medical professional can give to a septic shock patient. However most of those treatments are administered in a hospital setting. Prehospital treatment and management for septic shock would include proper management of ABC’s (Airway, Breathing, Circulation), identifying the source of infection and treat accordingly if possible, and monitoring of the patient's vital signs. Not much definitively can be done in a prehospital setting but prehospital management is vital for patient survivability.Some complications that can occur as a result of septic shock include acute respiratory distress syndrome (ARDS), respiratory failure, heart failure, renal failure or injury, and abnormal blood clotting. Sepsis is listed by The Agency for Healthcare Research and Quality as the most expensive condition treated in the U.S. with an overall cost of more than $20 billion in 2011. Sepsis and sepsis
Adirim, Terry A. “Concussions in Sports and Recreation.” Clinical Pediatric Emergency Medicine 8.1 (2007): 2-6. Print.
When diagnosed with hyponatremia treatment usually immediately begins. Treatment must be a restriction of both salt and water (Gheorghita et. al 2010). Hyponatremic patients must receive a slow increase in sodium with a restriction of liquids. Intravenous hypertonic saline solution of 3% NaCl can be administered to patients who have been diagnosed with hyponatremia. There is a precise formula that is used in determining the quantity of NaCl that is used in increasing sodemia and the rate at which it should be administered (Gheorghita et. al 2010).
Ridley, E. J., Dietet, B. N., & Davies, A. R. (2011). Practicalities of nutrition support in the intensive care unit: the usefulness of gastric residual volume and prokinetic agents with enteral nutrition. Nutrition, 27(5), 509-512. doi:10.1016/j.nut.2010.10.010
Sepsis is defined as an exaggerated, overwhelming and uncontrolled systemic inflammatory response to an initially localised infection or tissue injury, which may lead to severe sepsis and septic shock if left untreated (Daniels, 2009; Robson & Daniels, 2013; Dellinger et al, 2013; Perman, Goyal & Gaieski, 2012; Vanzant & Schmelzer, 2011). Septic shock can be classified by acute circulatory failure as a result of massive vasodilation, increased capillary permeability and decreased vascular resistance in the body, causing refractory hypotension despite adequate fluid resuscitation. This leads to irreversible tissue ischaemia, end organ failure and ultimately, death (McClelland & Moxon, 2014; Sagy, Al-Qaqaa & Kim, 2013, Dellinger et al, 2013).
..., and initiate administration of mannitol for further control. Rapidly stabilize vital signs, and simultaneously acquire an emergent computed tomography (CT) scan.”
Sepsis is a life threating health condition and if not treated early can lead to shock, multiple organ failure and death (Ho, 2012). The main study of which practice has been based world-wide is the Surviving Sepsis Campaign. The Surviving Sepsis Campaign was developed to create evidence-based management guidelines. The Surviving Sepsis Campaign completed this by using an educational program to implement the guidelines by integrating their recommendations into resuscitation and management bundles (Marik, 2011). The first Surviving Sepsis Campaign Guidelines were published in Critical Care Medicine in 2004 with an updated version published in 2008 with the core of the recommendation's remained largely unchanged (Ahrens, 2011).
The current patient may be experiencing a range of traumatic injuries after his accident, the injuries that the paramedic will focus on are those that are most life threatening. These injuries include: a possible tension pneumothroax or a haemothorax, hypovolemic shock, a mild or stable pelvic fracture and tibia fibula fracture.