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fluidBloodTraumaV2_0804 - Fluids and Blood in Trauma...

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Fluids and Blood in Trauma Charles E. Smith, MD Professor of Anesthesia MetroHealth Medical Center Case Western Reserve University Cleveland, Ohio
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Objectives Overview of trauma Dx + Tx of shock Hypotensive resuscitation Crystalloid + blood products Intraop bleeding Cell salvage • O 2 carrying solutions rFVIIa
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“Drugs, ETOH, + stupidity have given me a steady paycheck for 30 yrs” Pat Dixon MHMC OR nurse
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ATLS Provider Manual Trauma Costs Leading cause of death, ages 1 - 44 yrs 60 million injuries annually in USA 30 million require medical care 3.6 million require hospitalization 9 million are disabling 300 k = permanent; 8.7 million= temporary Costs are staggering: > $100 billion annually, or 40% of health care $
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Goals of Fluid & Blood Therapy Restore DO 2, treat injuries, maintain CPP Prevent progression of shock Repay cellular O 2 ‘debt’ Restore coagulation Endpoints: normalization of multiple variables- pH, lactate, BE, urine, BP, HR, SPV, SV, pt/ptt, SvO 2 , CI, DO2, VO2
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Oxygen Delivery: DO 2 DO 2 = (CaO 2 x CO x 10) + (PaO 2 x 0.003) CaO 2 = Hg x 1.39 x % sat CaO 2 ~ 1/2 Hct, assume CO 5 L/min, 100% sat Hct 40 CaO 2 20 CO 5 DO 2 1000 Hct 30 CaO 2 15 CO 5 DO 2 750 Hct 20 CaO 2 10 CO 5 DO 2 500 Hct 10 CaO 2 5 CO 5 DO 2 250
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Oxygen Debt 1. Full recovery possible 2. Delayed repayment of O2 debt 3. Excessive O2 deficit w lethal cell injury Ref: Siegel JH. Trauma: Emergency Surgery and Critical Care
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Estimating Oxygen Debt Base deficit Lactate pH Mixed venous O 2
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Arterial Pulse Waveform Analysis SPV= difference between maximal + minimal values of systolic BP during PPV 2200 down: normally ~ 5 mm Hg due to venous return SPV > 15 mm Hg, or down > 15 mm Hg: highly predictive of hypovolemia LidCO/ PulseCO monitor: SPV, SV, SVV Jonas MM. Curr Opin Crit Care 2002;8:257-61
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ITACCS 2003 Monograph on Massive Transfusi Hemorrhagic Shock Class I: < 750 ml, < 15% blood volume: crystalloid Class II: 750-1500 ml, 15-30% blood volume crystalloid Class III: 1500-2000, 30-40% blood vol crystalloid, red cells Class IV: > 2000, > 40% blood vol crystalloid, red cells
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Hypotensive Resuscitation Attempts to normalize BP with fluids & blood during uncontrolled hemorrhage : disrupts clot, risk bleeding + mortality Animal model of uncontrolled hemorrhage: gp 1- no surgery, no fluid: 100% mortality @ 150 min gp 2- no fluid, surgery+fluid: 50% @ 90 m, 90% @ 3 d gp 3- hypo resusc, MAP 40, surgery+fluid: no initial deaths, 40% @ 3 d gp 4- resusc to MAP 80, surgery+fluid: 80% @ 90 min, blood loss, all died J Am Coll Surg 1995;180:49
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Hypotensive Resuscitation, contd Randomized trial, penetrating torso trauma, urban center: immediate v. delayed fluids - mortality - LOS - complications in immediate gp Conclusions: Delayed fluid resuscitation acceptable if rapid dx + tx of injury Bickell et al: NEJM 1994;331:1005
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Dutton et al: J Trauma 2002;52:1141 RCT, trauma pts w SBP < 90; excluded head injury: Gp 1- fluid resusc to SBP 100 Gp 2- fluid resusc to SBP 70 No difference in survival: 93%, although ISS in gp 2 [23.9 v 19.5] Duration of bleeding similar between gps: ~ 3 h
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Boldt J: Can J Anesth 2004;51:500-13. Review
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