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So, as a general principal, fluid administration is limited in both damage control resuscitation (DCR) as a means of mitigating what's known ad the 'trauma triad'- acidosis, hypothermia and hypocoagulability. The three act in a triad- acidosis makes you hypocoagulable https://twitter.com/dempmcgee/status/1390808529297158145
/2 hypocoagulability makes you hypothermia, hypothermia adds to acidosis. Breaking this cycle is crucial in DCR. The two keys in the prehospital setting are hemorrhage control and limited fluid resuscitation. Hemorrhage control because it obviously limits blood loss.
/3 Limited fluid resuscitation because it prevents inappropriate dilution of the normal blood component ratio. (Red/plasma/platelets). As more fluid is administered, you can increase your blood pressure, but since the blood is diluted, it won't clot or carry O2 as well.
/4 So; we limit fluid unless there's no perfusion to the head. (SBP<90) In fact, research shows that mortality goes UP for excess fluid administered in both penetrating chest and abdominal trauma. (Head injuries are different- they do worse with lower BP, but
/5 the brain is a whole other kettle of fish).
Best evidence suggests that in penetrating trauma of the chest/abd pelvis, minimal fluid administration is key for optimizing survival until definitive surgical control. (Aka: Damage Control Surgery).
Best evidence suggests that in penetrating trauma of the chest/abd pelvis, minimal fluid administration is key for optimizing survival until definitive surgical control. (Aka: Damage Control Surgery).
/6 So, the EMS focus is on hemorrhage control either via direct pressure dressings for venous bleeds, tourniquets for arterial bleeds in extremities and direct pressure on no compressable/ non-dressable sites. (Groin/neck/axilla).
/8 Fluid resuscitation should be titrated to a SBP of 90- and if you don't have a cuff to a radial pulse and the patient being conscious. (For those of you that your palp pulses forgot, Carotid is 60-70, femoral is 70-80, radial is 80-90). Radial pulse presence
/9 means that your SBP is 80-90 or greater, which will keep your brain alive in most adults.
/10 Fluid can be administered in low volumes, 250-500 ml at a time, and titrated to the pulse. The days of just spiking two bags and letting them go are gone. You may see it in the trauma bay, but it's simultaneously done with the massive transfusion protocol activation.
/11 Tl;Dr- low volume resuscitation to an SBP of 90 and hemorrhage control. Those are the best current evidence interventions to get your patient to the bay alive and optimize them for resuscitation.
/12 References : https://www.jems.com/patient-care/trauma/damage-control-resuscitation-principles-adapted-for-ems-civilian-trauma/
/13 Reference: https://jts.amedd.army.mil/assets/docs/cpgs/JTS_Clinical_Practice_Guidelines_(CPGs)/Damage_Control_Resuscitation_12_Jul_2019_ID18.pdf
/14 Reference: https://pubmed.ncbi.nlm.nih.gov/30189070/
/15 Reference: https://www.itrauma.org/wp-content/uploads/2019/05/Current-Thinking-Damage-Control-Resuscitation-May-2019.pdf
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@DempMcgee @MedicPlastic @combatbuttwiper
Feel free to tag anyone else who can use this, fellas.
@DempMcgee @MedicPlastic @combatbuttwiper
Feel free to tag anyone else who can use this, fellas.
@katearthsis - you too sis. You're gonna be running a bay someday.
