II. Precautions
- Recognize signs of shock early
- Tachycardia
- See Heart Rate for normal ranges for age
- Early warning sign of shock in most cases
- Cold and tachycardic is shock until proven otherwise
- However can be misleadingly normal in cases of Delayed Tachycardia
- Avoid relying on late, unreliable markers of shock
- Hemoglobin And Hematocrit may not reflect massive blood loss for hours
- Blood Pressure does not fall until all compensatory mechanisms are overwhelmed
- Tachycardia
- Promptly identify shock cause
- Most cases are Hemorrhagic Shock in the Trauma patient
- See Hemorrhagic Shock
- Emergent surgical Consultation
- Paramount to locate and stop the source of bleeding (and replace losses)
- Consider other forms of shock
- Tension Pneumothorax
- Cardiac Tamponade
- Neurogenic Shock secondary to Spinal Cord Injury (not due to isolated intracranial injury)
- Most cases are Hemorrhagic Shock in the Trauma patient
III. Indications: Signs of shock
- Mottled or pale color
- Cool skin
- Diminished peripheral pulses
- Delayed capillary pulses despite normal Ambient temp
- Mental status changes
- Oliguria
- Shock may be present despite normal Blood Pressure
IV. Preparations: Available Fluids for Volume Expansion
- Crystalloid Isotonic Solution
- Colloid Solution
-
Blood Products
- Inadequate improvement after 2 crystalloid boluses (old recommendation)
- Newer guidelines as of 2013 suggest early transition to replacing blood loss with Blood Products
V. Protocol: Fluid Replacement
- See Hemorrhagic Shock
- See precautions above
- Approach
- Initial fluid Resuscitation is with crystalloid
- Heated crystalloid (to 39 C or 102.2 F) is preferred to prevent Hypothermia
- Closely monitor for response to fluid Resuscitation
- Rapid and sustained response to fluid bolus (<10-20% blood loss)
- Monitor for decompensation (especially if risk of Delayed Tachycardia)
- Transient response to fluid bolus (20-40% blood loss, ongoing)
- Emergent Blood Transfusion
- Close monitoring for surgical intervention
- No response to fluid bolus (>40% blood loss)
- Emergent surgical or angiographic intervention
- Emergent Blood Transfusions (assume Massive Hemorrhage)
- Rapid and sustained response to fluid bolus (<10-20% blood loss)
- Initial fluid Resuscitation is with crystalloid
- Initial fluids - Replace first liter with crystalloid
- Isotonic crystalloid (Normal Saline and Lactated Ringers are equivalent) is standard of care
- Hypertonic Saline may be used instead (?antiinflammatory) but studies do not support benefit
- Bulger (2011) Ann Surg 253(3): 431-41
- Do not use dextrose solutions
- Induces osmotic diuresis
- Results in Hypokalemia
- Worsens ischemic brain injury
- Subsequent fluids (after first liter)
- Replace blood loss with Packed Red Blood Cells
- Massive Blood Transfusion is typically accompanied by Platelet and Plasma Transfusion
- References
- Inaba and Herbert in Majoewsky (2013) EM:Rap 13(7): 4
VI. Monitoring: General
- See Central Venous Pressure (CVP)
- Inferior Vena Cava Ultrasound for Volume Status
- Reassess systemic perfusion after each bolus
- Urinary output
- Normal Urine Output is >0.5 ml/kg/h in adults (>1 ml/kg/h in children, >2 ml/kg/h in infants)
- Level of Consciousness
- Peripheral perfusion
- Blood Pressure
- Do not rely solely on blood presure as a marker of improvement (may simply reflect Vasoconstriction)
- Heart Rate
- Urinary output
- Move swiftly to replacement of Blood Products if no response to Intravenous Fluids
- Large volume replacement is not a substitute for identifying and stopping active Hemorrhage
VII. Dosing
- Bolus Volumes given rapidly (<20 minutes)
- Adult: 1-2 Liter Bolus IV
- Child: 20 ml/kg LR or NS IV or IO
- Use 35-50 cc syringe attached to inline 3-way stop-cock
- Repeat dosing
- Assume Hemorrhagic Shock and replace with Blood Products
- May require 2-3 boluses within first hour until Blood Products
- Septic Shock is rare in Trauma, but may require 4 boluses in first hour
VIII. References
- (2012) ATLS Manual, 9th ed, American College of Surgeons