Fluid Resuscitation in trauma

[Fraser.g]

This is a break off from the TCCC thread.
I feel that this topic is incredibly important not only for the pre-hospital or field medic but also for the lay (combat arms) who will be receiving this care when the s**t hits the fan.

Rapid fluid resuscitation in the pre hospital or field environment is comming under review. The school of thought today is that bolusing large amounts of crystaloid is detrimental to the outcome of the patient.

The British National Institute for Clinical Excellence (NICE) has put out several advisories on the topic.
Most of these are reviews of earlier works out of Canada and the US.
http://www.nice.org.uk/page.aspx?o=101664

The conclusions that they seem to reach is that fluid recitation may be detrimental to the positive outcome of the patient but more research needs to be done to finalize any conclusions.

There are a multiple discussion papers on the subject each for or against this therapy. Here are a few I have gone over. The first one is a basic layout of the issues and is a good starting point for anyone interested but not yet knowlagable in the subject. Unfortunately it is from Jan 2003 and therefore is slightly outdated in the ATLS protocols.
http://www.theiaforum.org/january2003.htm

Here are some others

http://www.trauma.org/resus/permissivehypotension.html

http://www.ncchta.org/execsumm/summ431.htm

If anyone has any others or comments
Let the learning continue!

GF

 

[PRL ER NO]

First, let me thank you for starting this new thread.

The topic of fluid resucitation, as you stated, has come again under review.   Earlier this month, I was at a Trauma Conference in Michigan.   Capt(N) Dr Peter Rhee was at the conference and gave a very interesting talk about fluid resucitation annd it's pro's and con's.   He does suggest IV locks (saline and heparin locks) in all trauma casaulities in the battle field.   However, as some of you articles, attachments, suggest the use of permissive hypotension is not necessary a bad thing.

A link to Capt(N) Rhee's next conference, in Las Vegas http://www.trauma-criticalcare.com/program.html

A power point presentation about the pit falls of Lactated Ringers' resuscitation http://www.nbrl.org/ppt/storagestability.ppt

And Capt(N) Dr Rhee is published in the Journal of Trauma in reference to his research on fluid resuscitation.


Just more information

 

[Fraser.g]

Good stuff

Keep it comming. I liked the presentation on RL.

GF

 

[Gunnar]

Just for the uninitiated, what's fluid resucitation, and what does it have to do with trauma?

Just curious.

 

[Fraser.g]

The human body is about 80% water. This water caries different electrolites like salt and potassium as well as formed bodies like red blood cells and platelets. The balance of these materials is critical for the survival of the body.

As advanced as the art of war is the basic idea is to poke as many holes in the enemy as possible in order to make him leak enough fluid so that he can not continue to attack you.

Fluid resuscitation is the science of replacing some of that naturally occurring fluid with stored body fluids like blood transfusions or with man made materials like IV solutions. The debate is when do you start giving back that fluid, which fluid do you use and how much.

If you give to much fluid with out the formed bodies then you dilute the blood and it can no longer Cary out its function properly. It will not carry oxygen to the tissues, carry away waste or clot properly. If you give to little then the blood pressure (the hydraulic system) on which the body depends to circulate the blood will fail. If you give too much then the over pressure will force the fluid where it is not meant to be by going through the walls of the vessels or bursting the vessels them selves. Each of these scenarios we refer in the medical field as a "bad thing".

The other problem is that stored body fluids are very sensitive to temperature. If they are in an adverse condition for any length of time, that is to say out of the fridge or the body, they will start to break down and become useless. This means that the field medic will not be brining blood products out in his jump bag any time in the future.

And so the debate rages.

I hope this gives you some insight as to why the medical members of this board are so passionate about IV drips and their use.

GF

 

[medicineman]

I think one of the biggest things in this whole debate is to get across to the people who all want to start IV's just because the Parachute Regt was taught them in the Falklands is that ABC's are more important than getting that line in.  Like was stated earlier, people want to think they are helping someone - so keep that airway open and stop or control the bleeding, it goes a long way.  One paper I read recently on combat and disaster medicine states that most casualties won't initially need an IV.  Most of us with long lines of evac want to put one in just in case the person crumps, which is generally accepted to be fine - so use a saline lock to keep your work space clear.

The problem I always hear from the end recipients of not receiving much in the way of IV training was "we did this in Yugo in 94,"etc, and in fact I taught guys to do that - hey my ass was on the line too - but times change and so does medical research results.  For the combat arms guys, we aren't slagging down your skill sets by any stretch of the imagination - it's just that things change and therefore so must our collective thinking.  IV use is one of those things. 

Incidentally - about the Falklands thing - I saw some of the tape shot during the bombing of the Sir Galahad and vividly remember watching some Paras trying to get a line into one of the guys.  The two were very busy and pre-occupied with his arm while his airway and other injuries were unattended; it appears that they never found the vein...

Food for thought.

MM

 

[PRL ER NO]

One paper I read recently on combat and disaster medicine states that most casualties won't initially need an IV.  



I agree, medicineman, I was recently at a conference with a MD form the US Navy.   The key point of one of his talks was the need vs no need for intial injury battle field casaulties and damage to the body systems.

The education of "troops" with the skill of intervenous is not the best idea for the troops.   The key word is "skill".   I have been working a a nurse for 11+ years and still can not get very IV.   To have unskilled troops starting IV in battlefield sit's is something that should not be explored at this time.   Not to over look the problem of disease.

More food for thought

 

[Fraser.g]

Yes the key word is Skill, and yes we can teach the combat arms to do the skill. We could even, given the support of the comand structure, maintain that skill at an acceptable level. The big thing here is that the new literature says that it would be a waste of time teaching the skill as it is not medically indicated for high volume fluid boluses in the field.
If the peer reviewed literature changes, then we can re-visit teaching the combat arms and non-medical pers to attain and maintain IV access. The thinking now is that with the limited time dedicated to first aid on pre-deployment work up the time would be better spent with ABCD (Airway Breathing Circulation Deadly bleeds) as opposed to IV access. This brings us back to the TCCC course in what ever manifestation the powers that be decide to bring to the combat arms.

By the way no one gets every poke. I don't care how gifted you are and where you work. I am in the MO and work the ER as well. Anyone who claims to get close to 100% of starts is lying and I will not let them near me because they have waaay too much bravado and too little brains.

 

[Armymedic]

In discussion with my non medical team I am supporting, I stated that the only two indications by which they would start an IV (if I choose to teach them, and maintain thier skills) would be:

1. I told them too,
2. For rehydration if I am not around.

I believe I was convicing when I proved to them that stopping the bleeding and rapid transport of cas to aid is much better use of time and resources.

 

[medicineman]

So old dogs are learning new tricks?

MM

 

[Fraser.g]

The old dog that does not learn new tricks is one that should be put down. The face of war is dynamic and so is the treatment of those effected by it.
Learn and adapt or get out of the way, there can be no middle ground.

GF

 

[medicineman]

That might not leave us with alot of soldiers left.

MM

 

[Fraser.g]

LOL

True, but are you referring to "putting down old dogs that refuse to learn new tricks" or soldiers who get mediocre or detrimental care due to health care professionals who refuse to base their care practices on new research and care modalities?

Both will kill or maim un-necessarily just as surly as a 7.62 round to the center of mass.

GF

 

[medicineman]

Yes, though mainly the former.  It seems there are still people out there reading too many books about the Falklands.

MM

 

[nsmedicman]

I can only speak from the civi side of things, but from what we are told, a bit of hypotension in the trauma victim isn't necessarily a bad thing. It decreases work load on the major organs (mainly the heart). Saline locks are a good thing, especially if evacuation is delayed, just in case your patient starts to crash. The official party line (protocols) where I work is with a BP of less than 100 systolic, two large bore IVs are indicated, and fluid is delivered in 250mls intervals, titrated to 100 systolic. Failing that, maintain ABCs, plug the holes and evac rapidly. The only true cure for trauma is a surgeon with a knife, a brain, and a really good pair of hands.