Principles of fluid therapy in a massive trauma and hemorrhage.

1. Principles of fluid therapy in a massive trauma and hemorrhage. • Waldemar Machała Ghazni, Afghanistan, September 2012 Department of Anesthesiology and Intensive Care The Military Teaching Hospital-CSW The gen. bryg. Stefan Hubicki Military Center of Medical Education

2. Estimated blood volume (EBV) Hematocrit – 40% Hematocrit RBC (PRBC) – on average approx. 60% Miller’s Anesthesia, 7th edition. 2010: chapter 82. A practice of anesthesia for infants and children, 4th edition: chapters 8 and 10. C Cote. 2009.

3. Hemorrhage / transfusion • Loss of 1.5 mL of blood/KG/min. for 20 mins. • Loss of 150 mL of blood/min. within 1 hr. • Transfusion of 50 % of circulating blood volume within 3 hrs. • Transfusion of one volume of circulating blood within 24 hrs. Keel M et al: Pathophysiology of trauma. Injury 2005; 36: 691-671.

4. Shock State of inadequate oxygen supply to cells University of Wisconsin Department of Surgery. Circulatory collapse National Institute of General Medical Sciences. • Hypovolemic. • Obstructing. • Cardiogenic. • Distributive. Hinshaw LB, Cox BG: The fundamental mechanisms of shock, New York, 1972. Plenum Press. Rodriguez RM, Rosenthal MH: Etiology & Pathophysiology of shock. W: Murray MJ, Coursin DB, Pearl RG, Prough DS. eds. Critical care medicine - Perioperative management. Lippincott William & Wilkins, London. 2003; 192-205.

5. Hypovelemic shock Hinshaw,Cox 1972 • Hemorrhagic. • Visible. • Invisible. • Non-hemorrhagic. Hinshaw LB, Cox BG: The fundamental mechanisms of shock, New York, 1972. Plenum Press. Rodriguez RM, Rosenthal MH: Etiology & Pathophysiology of shock. W: Murray MJ, Coursin DB, Pearl RG, Prough DS. eds. Critical care medicine - Perioperative management. Lippincott William & Wilkins, London. 2003; 192-205.

6. Blood loss resulting from bodily injuries Lung: 1000 mL (each side) Arm: 800 mL Liver: 2000 mL Spleen: 2000 mL Forearm: 400 mL Pelvis: >5000 mL Thigh: 2000 mL Crus: 1000 mL

7. Basics for fluids tranfusion after the trauma O2flow = [CO X Hgb X SaO2 X k] + [CO X PaOa x 0.003] • The quickest possible restoration of tissue oxygenation. • Causing the smallest possible biochemical abnormalities. • Protection of renal functions. • Avoiding fluids transfusion-related complications. Smith JP, Bodai BI, Hill AS i wsp.: Prehosoital stabilization of critically injured patients: a failed concept. J Trauma 1985; 25: 65-70.

8. Time for fluid therapy onset • Pre-hospital. • Hospital emergency ward. • During emergency operations. • In ICU. Smith JP, Bodai BI, Hill AS i wsp.: Prehosoital stabilization of critically injured patients: a failed concept. J Trauma 1985; 25: 65-70.

9. On-site activitiesUS Army Wilson WC, Grande CM, Hoyt DB in: Trauma. Emergency resuscitation. Perioperative anesthesia. Surgical Management. Informa Healthcare USA. 2007.

10. On-site strategy of handling the injured Basic life-saving actions Spine immobilization. Fractures immobilization. Dressing external hemorrhage. Bag mask ventilation. • Scoop and run. • Stay and play (stay and treat). Advanced life-saving actions Final securing of the airways. Decompression of pneumothorax. Coniotomy/ tracheotomy. IV access and fluids transfusion. Berlot G, Bacer B, Gullo: Controversial aspects of the prehospital trauma care. Crit Care Clin 2006; 22: 457-468. Haas B, Nathens AB: Pro/con debate: is the scoop and run approach the best approoach to trauma services organization? Critical Care 2008; 12: 224 (http://ccforum.com/content/12/5/224.

11. On-site actionsScoop and run, or Stay and play? In certain situations, starting rescue actions on site may prolong the time of definite life-saving actions onset1,2,3: • Attempts of artificial airways – instead of bag mask ventilation and transportation to the hospital. • Worse (adverse) result of therapy (next to statistically more frequent occurrence of coagulopathy and multiorgan failure) with the patients who were secured with vascular angioaccess and fluids transfusion and who: • Were diagnosed with penetrating bodily trauma4,5. • Were not secured as far as the hemorrhage site is concerned6. Berlot G, Bacer B, Gullo: Controversial aspects of the prehospital trauma care. Crit Care Clin 2006; 22: 457-468. Haas B, Nathens AB: Pro/con debate: is the scoop and run approach the best approoach to trauma services organization? Critical Care 2008; 12: 224 (http://ccforum.com/content/12/5/224. Bulger EM, Maier RV: Prehospital care of the injured: what’s new. Surg Clin North Am 2007; 87: 37-53. Bickell WH, Wall MJ Jr, Pepe PE i wsp.: Immediate vs delayed fluid resuscitation for hypotensive patients with penetrating torso injures. N Engl J Med. 1994; 331: 1105-1109. Ivatury RR, Nallathambi MN, Roberge RJ i wsp.: Penetrating thoracic injures: in-field stabilization vs prompt transport. J Trauma 1987; 27: 1073. Smith JP, Bodai BI, Hill AS i wsp.: Prehosoital stabilization of critically injured patients: a failed concept. J Trauma 1985; 25: 65-70.

12. On-siteactionsScoop and run, orStay and play? With the patients: • With no possibility of final (temporary) hemorrhage securing1,2,3: • Ectopic pregnancy. • Placenta previa. • Premature placental disruption. • Penetrating injuries (vascular injuries in 90%)4. • Internal hemorrhage. • In urban conditions. • In the circumstances when the ETA to the hospital is relatively short (4-12 mins.)5,6. No attempts to cannulate the vessel or fluids transfusion should be made; instead: • The patient should be transported to the hospital a.s.a.p. • The hospital should be informed about the necessity to prepare the operating room and the surgical team (surgeons and anesthesiologist). Kelly JF, Ritenour AE, McLaughlin DF iwsp.: Injury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: 2003-2004 vs 2006. J Trauma 2008; 64: 21-26. Clouse WD, Rasmussen TE, Peck MA iwsp.: In-theater management of vascular injury: 2 years of the Balad Vascular Registry. J Am CollSurg 2007; 204: 625-632. Eastridge BJ, Jenkins D, Flaherty S iwsp.: Trauma system development in a theater of war: experiences from Operation Iraqi Freedom and Operation Enduring Freedom. J Trauma 2006; 61: 1366-1372. Sanchez GP, Peng EWK, Marks R iwsp.: Scoop and run strategy for a resuscitative sternotomy following unstable penetrating chest injury. InteraciveCardiovascThoracSurg 2009; 10: 467-469. Isenberg D: Does advanced life support provide benefits to patients? A literature review. PrehospDisast Med. 2005; 20: 265-270. Smith RM, Conn AKT: Prehospital care – scoop and run or stay and play? Injury Int J Care Injured 2009; 40S4: 23-26.

13. On-siteactionsScoop and run, orStay and play? With the patients with no possibility of final (temporary) hemorrhage securing1,2,3 no attempts to cannulate the vessel or fluids transfusion should be made, instead: • The patient should be transported to the hospital a.s.a.p.. • The hospital should be informed about the necessity to prepare the operating room and the surgical team (surgeons and anesthesiologist). Adverse effects of fluids transfusion with the lack of securing the hemorrhage site: • Increased bleeding from damaged vessels. • Smaller clot-forming abilities in the site where the vessels are damaged. • Increase in the hematocrit and the hemoglobin levels. • Lowering of the clotting factors levels. • Risk of hypothermia. Kelly JF, Ritenour AE, McLaughlin DF i wsp.: Injuryseverity and causes of death from OperationIraqiFreedom and OperationEnduringFreedom: 2003-2004 vs 2006. J Trauma 2008; 64: 21-26. Clouse WD, Rasmussen TE, Peck MA i wsp.: In-theater management of vascularinjury: 2 years of the BaladVascular Registry. J Am CollSurg 2007; 204: 625-632. Eastridge BJ, Jenkins D, Flaherty S i wsp.: Trauma system development in a theater of war: experiences from OperationIraqiFreedom and OperationEnduringFreedom. J Trauma 2006; 61: 1366-1372.

14. On-siteactionsScoop and run, orStay and play? Kelly JF, Ritenour AE, McLaughlin DF i wsp.: Injuryseverity and causes of death from OperationIraqiFreedom and OperationEnduringFreedom: 2003-2004 vs 2006. J Trauma 2008; 64: 21-26. Clouse WD, Rasmussen TE, Peck MA i wsp.: In-theater management of vascularinjury: 2 years of the BaladVascular Registry. J Am CollSurg 2007; 204: 625-632. Eastridge BJ, Jenkins D, Flaherty S i wsp.: Trauma system development in a theater of war: experiences from OperationIraqiFreedom and OperationEnduringFreedom. J Trauma 2006; 61: 1366-1372.

15. On-siteactionsScoop and run, orStay and play? With the patients whose hemorrhage was temporarily secured, e.g. by applying:1,2,: • Pressure dressing. • Tourniquet. • Polymer dressing (e.g. Quick-Cloth). you should: • Secure two peripheral vascular angioaccess points (14G). • Apply infusion of 0.9% NaCl, or lactatad Ringer’s solution (1000 mL) – if SAP< 90 mm Hg (or 110 mm Hg – cerebral injuries). • Maintain MAP: 40-50 mm Hg. • In acute hypovolemiapathophysiology, decrease in preload prevails – hence, the only purposeful action is intravascular volume replacement. • Catecholamines increase afterload and are not recommended at this stage of shock. • Transport the patient to the hospital. • Inform the hospital about the necessity to prepare the operating room and the surgical team (surgeons and anesthesiologist). Isenberg D: Doesadvanced life supportprovidebenefits to patients? A literaturereview. PrehospDisast Med. 2005; 20: 265-270. Smith RM, Conn AKT: Prehospitalcare – scoop and run orstay and play? InjuryInt J CareInjured 2009; 40S4: 23-26. Jureczko R: Hemostaza w urazach wielonarządowych. Przegląd Urologiczny 2004: 5.

16. On-siteactionsScoop and run, orStay and play? With the patients whose hemorrhage was temporarily secured, e.g. by applying:1,2,: • Pressure dressing. • Tourniquet. • Polymer dressing (e.g. Quick-Cloth). You should: • Secure two peripheral vascular angioaccess points (14G). • Apply infusion of 0.9% NaCl, or Ringer’s solution (1000 mL) – if SAP< 90 mm Hg (or 110 mm Hg – cerebral injuries). • Keep MAP: 40-50 mm Hg. • In acute hypovolemiapathophysiology decrease of preload prevails – hence, the only purposeful action is intravascular volume replacement. • Catecholamines increase afterload and are not recommended at this stage of shock. • Transport the patient to the hospital. • Inform the hospital about the necessity to prepare the operating room and the surgical team (surgeons and anesthesiologist).. • Watch out for: • Pain.lactated • Psychomotoragitation. • (result of hypoxia) Isenberg D: Doesadvanced life supportprovidebenefits to patients? A literaturereview. PrehospDisast Med. 2005; 20: 265-270. Smith RM, Conn AKT: Prehospitalcare – scoop and run orstay and play? InjuryInt J CareInjured 2009; 40S4: 23-26. Jureczko R: Hemostaza w urazach wielonarządowych. Przegląd Urologiczny 2004: 5.

17. On-siteactionsScoop and run, orStay and play? Isenberg D: Doesadvanced life supportprovidebenefits to patients? A literaturereview. PrehospDisast Med. 2005; 20: 265-270. Smith RM, Conn AKT: Prehospitalcare – scoop and run orstay and play? InjuryInt J CareInjured 2009; 40S4: 23-26. Jureczko R: Hemostaza w urazach wielonarządowych. Przegląd Urologiczny 2004: 5.

18. On-siteactionsUS Army ? In such circumstances, we may: • Allow for hypotension +/- ?. • Avoid hemorrhage volumeincrease. • Consider small volume resuscitation (SVR). Wilson WC, Grande CM, Hoyt DB w: Trauma. Emergencyresuscitation. Perioperativeanesthesia. Surgical Management. InformaHeathcare USA. 2007. Rekomendacje dla podawania stężonej soli w HAES w NATO - http://ftp.rta.nato.int/public/Pubfulltext/RTO/MP/RTO-MP-HFM-109///MP-HFM-109-07.pdf

19. Alternativein fluid therapy? ? Wilson WC, Grande CM, Hoyt DB w: Trauma. Emergencyresuscytation. Perioperativeanesthesia. Surgical Management. InformaHeathcare USA. 2007. Rekomendacje dla podawania stężonej soli w HAES w NATO - http://ftp.rta.nato.int/public/Pubfulltext/RTO/MP/RTO-MP-HFM-109///MP-HFM-109-07.pdf

20. On-siteactionshemorrhagestopped but co-existingshock • HyperHAES because: • Instant increase of arterial blood pressure and cardiac output, with decreased systemic vascular resistance (SVR). • Instant microcirculation flow increase. • Lowering adverse effects of ischemia and reperfusion. • Increase of diuresis resulting from improved organ perfusion. • Increase in survival ratio. Kreimeier i Messmer– experimental and clinicalstudies.

21. HyperHAES • HyperHAES→ 6% HAES (200/ 0.5) + 7,2% NaCl → 250 mL bags. • Na+ 1232 mmol/ L. • Cl- 1232 mmol/ L. • pH 3.5 – 6.0. • Osmolarity: 2464 mOsm/ L. • COP 36 mm Hg. • Dosage: 4 mL/ KG (approx. 250 mL). • Infusion volume: 2 – 5 minutes. …

22. HyperHAES - effects • Hypertonic solution of NaCl quickly increases circulating blood volume through transferring the fluid from extravascular to intravascular space. • 7.2% NaCl included in the HyperHAES solution is responsible for inducing the mechanism of quick endogenous fluid transfer. • Colloid present in the solution binds water which ensures long-lasting volume effect. • Endogenous water is mobilized mainly from the area of erythrocytes and vascular endothelial cells: • Circulating blood volume is rapidly increased (3 – 4x of the transfused volume). • Microcirculation flow appears through endothelial cells dehydration thus increasing oxygen supply to tissues. …

23. Ideal solution for fluid resuscitation: • Transfusion of small volume improves perfusion. • Beneficial effect on oxygen extraction in tissues: • Oxygen supply. • Oxygen use. • Proper composition taking into account pH measure and electrolyte composition. • Sterility. • Suitably long effects. • Stability. • Ready to use. • Inexpensive. …

24. Crystalloids …

25. Colloids …

26. Crystalloids vs. colloids volume effect …

27. Time to start fluid therapy • Pre-hospital. • Hospital emergency ward. • During emergency operations. • In ICU. Smith JP, Bodai BI, Hill AS i wsp.: Prehosoitalstabilization of criticallyinjuredpatients: a failedconcept. J Trauma 1985; 25: 65-70.

28. Hospitalactivities Stop the bleeding – great ‘five’ of hemorrhages: • External: • Clinical examination. • BP monitoring. • Chest: • Clinical examination and chest X-ray. • Pulmonary drainage. • Abdomen: • Clinical examination. • DPO, FAST, CT, laparoscopy, laparotomy. • Pelvis: • Clinical examination. • X-ray, CT, angiography. • Long bones. Recognize the shock paying attention to possible problems: • Co-existing CNS injury. • Age. • Body build (athletic). • Medication taken. • Hypothermia. • Pacer. • Clothes (waterproof; Velcro). Isenberg D: Doesadvanced life supportprovidebenefits to patients? A literaturereview. PrehospDisast Med. 2005; 20: 265-270. Smith RM, Conn AKT: Prehospitalcare – scoop and run orstay and play? InjuryInt J CareInjured 2009; 40S4: 23-26.

29. Hospital activities US Army • Rescue actions depending on response to fluid resuscitation (to fast transfusion): • 2000 mL of lactated Ringer’s solution (adults). • 20 mL/KG of lactated Ringer’s solution (children). Wilson WC, Grande CM, Hoyt DB w: Trauma. Emergencyresuscitation. Perioperativeanesthesia. Surgical Management. InformaHeathcare USA. 2007.

30. Purpose of fluid therapy US Army Concerns exclusively young and healthy people without co-existing CNS injury. Early resuscitations ends with final securing of the hemorrhage spot. Wilson WC, Grande CM, Hoyt DB w: Trauma. Emergencyresuscitation. Perioperativeanesthesia. Surgical Management. InformaHeathcare USA. 2007.

31. DIC andACoTScriteria1,2 • Coagulopathy (on-site/ in the hospital)4,5,6: • Acute coagulopathy of traumatic stress (ACoTS). • Disseminated intravascular coagulation (DIC). • Platelet count: • <50 000 2 pts. • 50 – 100 000 1 pt. • Fibrinogen: • < 1g/L 1 pt. • D-dimers: • > 4 mg/L 3 pts. • 0.39-4 mg/L 2 pts. • INR: • >2,3 2 pts. • 1.4-2.3 1 pts. • Criteria for diagnosing DIC: • ≥ 5 pts. • Criteria for diagnosing acute coagulopathy of traumatic stress (ACoTS): • APTT or/and INR: • >35 secs.or 1.2. Johansson PI, Sorensen AM, Perner A i wsp.: Disseminatedintravascularcoagulationoracutecoagulopathy of trauma shockearlyafter trauma? Anobservationalstudy. Critical Care 2012; 15: 272-285. Taylor FB, Jr, Toh CH, Hoots WK i wsp.: Towardsdefinition, clinical and laboratorycriteria, and a scoring system for disseminatedintravascularcoagulation. ThrombHaemost 2001; 86: 1327-1330.

32. Whyisthediscussionabout DIC and ACoTS so important? 1,2,3 Because coagulation disorders appear as a result of: • Hemorrhage. • Traumatic stress. And are worsened: • Resulting from physical status (co-existing illnesses). • After infusion of 2000 mL of fluids. • And are further increased in the course of: • Hypoperfusionwithall its consequences. • Hypothermia. • Acidosis. • Hypercatecholaminemia. • Electrolyte imbalance. Johansson PI, Sorensen AM, Perner A i wsp.: Disseminatedintravascularcoagulationoracutecoagulopathy of trauma shockearlyafter trauma? Anobservationalstudy. Critical Care 2012; 15: 272-285. Taylor FB, Jr, Toh CH, Hoots WK i wsp.: Towardsdefinition, clinical and laboratorycriteria, and a scoring system for disseminatedintravascularcoagulation. ThrombHaemost 2001; 86: 1327-1330. Shaz BH, Winkler AM, James AB i wsp.: Pathophysiology of early trauma-inducedcoagulopathy: emergingevidence for hemodilution and coagulationfactordepletion. J Trauma 2011; 70: 1401-1407.

33. Monitoring clinicalindicatorsdenotingproperperfusion • Mean arterial pressure. • Perfusion pressure: cerebral and visceral: • State of consciousness. • Diuresis. • Capillary refill. • Peripheral perfusion (mottled skin). • Temperature of peripheral body parts (cold feet, hands). • Lactates concentration. • Gasometry (pH, BE, HCO3-). • Mixed venous oxygen saturation (SvO2). • CO2 partial pressure in mixed venous blood. • CO2 partial pressure in tissues (StCO2). • O2 partial pressure in muscles (StO2). Marik PE, Monnet X, Teboul JL: Hemodynamicparameters to gouide fluid therapy. Annals of intensivecare 2011; 1: 1. http://www.annalsofintensivecare.com/content/1/1/

34. Bloodtransfusion • Indications for transfusion: • Ischemia, Hgb < 7 g/dL. • Hematocrit < 25%. • Elderly patients with co-existing cardiac disease. • Increased oxygen demand. • Maintained Hgblevels: 7-9 g/dL. Miller’sAnesthesia, 7thedition. 2010: chapter 82. A practice of anesthesia for infants and children, 4thedition: chapters8 and 10. C Cote. 2009.

35. Loss of thecirculatingbloodvolume(EBV – estimated blood volume) Hematocrit– 40% Hematocrit RBC (PRBC) – on averageapprox. 60% Miller’sAnesthesia, 7thedition. 2010: chapter 82. A practice of anesthesia for infants and children, 4thedition: chapters 8 and 10. C Cote. 2009.

36. End of fluid resuscitation • Effective oxygen therapy resulting in the increase of SpO2>97%. • Mechanical intubation and ventilation: • Protection of lower airways: • Resolving of oxygenation abnormalities (FiO2<60% with SpO2>97%). • Resolving of ventilation impairments (ETCO2<60 mm Hg). • Replenishment of circulating blood volume (colloids, crystalloids, blood products): • CVP approx. 20 cm H2O. • Hgb: 10-12 g/dL. • Positive result of implemented therapy (including catecholamines) resulting in: • HR within: 50-120/min. • MAP within: 70-110 mm Hg. • Increase in the value of ScvO2>65%. • Decrease in lactates concentration <2 mmol/L.

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