14.

0 Fluid Therapy Trauma Cases

Learning Outcomes
By the end of this section the learner should be:
Able to recognise shock
Identify probable cause
Be aware of the principles of management
Based on ATLS principles

Definition of shock
Where a circulatory abnormality results in inadequate organ perfusion and tissue
oxygenation.
Initial management steps:
The first step in managing shock in an injured patient is the recognition of its
presence. This is based on recognising the presence of inadequate organ
perfusion and tissue oxygenation.
The second step is to identify the probable cause of shock. In trauma cases this is
directly related to the mechanism of injury and usually takes the form of
hypovolaemic shock (due to haemorrhage) .
Management involves simultaneous recognition of the shock state, identification of
probable cause and initiating treatment.

PRINCIPLES
Cardiac output (CO) = Heart Rate (HR) x Stroke Volume (SV)
The venous system acts as a reservoir or capacitor for the blood volume and
contains nearly 70% of the total blood volume. The volume of venous blood returning
to the heart determines the myocardial muscle fibre length at end-diastole. Muscle
fibre length is related to contractility of myocardial muscle according to Starlings law.
Pathophysiology of blood loss
Early circulatory responses to blood loss are: compensatory i.e. progressive
vasoconstriction of cutaneous, muscle and visceral circulation to preserve blood flow
to the kidneys, heart, and brain.
Acute circulatory volume depletion together with the injury results in an increased
HR to attempt to preserve CO. Tachycardia is usually the earliest measurable
circulatory sign of shock.

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Compensatory mechanisms preserve venous return to some degree in early

haemorrhagic shock by contraction of the volume of blood in the venous system that
does not contribute to mean venous pressure, NB this mechanism is limited.
The most effective means of restoring and adequate CO and end-organ perfusion is
to restore venous return to normal by volume repletion.
Cellular damage occurs as a consequence of inadequate perfusion and oxygenation
due to a shift to anaerobic metabolism. Cells and their contents begin to degenerate
producing additional tissue swelling and eventually cellular death, compounding the
impact of blood loss and hypoperfusion.
Administration of isotonic electrolyte solutions in sufficient quantities helps combat
this process, therefore management is directed towards reversing this phenomenon
by providing adequate oxygenation, ventilation and appropriate fluid
resuscitation. Resuscitation may be accompanied by a marked increase in
interstitial oedema, which is caused by re-perfusion injury to the capillary-interstitial
membrane. The consequence of this is larger volumes of fluid may be needed than
initially anticipated.
Initial shock management is directed towards restoring cellular and organ
perfusion with adequately oxygenated blood. Frequent monitoring the patients
indices of perfusion is essential to evaluate their response to therapy and allow any
deterioration in their condition to be detected as early as possible.
Most injured patients with hypovolaemic shock demand the presence of a
surgeon to allow early surgical intervention to reverse the shock state.

INITIAL ASSESSMENT OF SHOCKED PATIENT

Recognition of shock
After the Airway and Breathing (ventilation) have been ensured the patients
Circulatory status must be assessed to identify early manifestations of shock
including: tachycardia and cutaneous vasoconstriction.
Systolic BP should not be used a sole indicator of shock as it will delay shock
recognition. Compensatory mechanisms may prevent a measurable fall in systolic
BP until up to 30% of the patients blood volume has been lost.
Attention should be directed to:
Usually early physiological
Pulse rate
responses to volume loss in
Tachycardia
most adults
Skin circulation
Cutaneous vasoconstriction
Respiratory rate
Pulse pressure (the difference between systolic and diastolic pressure)

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Any patient who is cool and tachycardic is in shock until proven otherwise.

Normal heart rate varies with age. Tachycardia by age is classified as:
Infants
Preschool
School to puberty
Adult

>160
>140
>120
>100

Elderly patients may not exhibit tachycardia due to the limited cardiac response to
catecholamine stimulation, concurrent use of -blockers or the presence of a pace
maker. A narrowed pulse pressure suggests significant blood loss and involvement
of compensatory mechanisms.
Clinical Differentiation of Shock Aetiology
Shock in trauma patients may be classified as haemorrhagic or non-haemorrhagic.
1.

Haemorrhagic shock is the most common cause of shock after injury. Virtually
all multiply injured patients will have some degree of hypovolaemia. Most cases
of non-haemorrhagic shock will respond partially or briefly to volume
resuscitation.
Therefore, if signs of shock are present, treatment should usually be
initiated as if the patient is hypovolaemic. NB once treatment is initiative
other aetiologies should be identified and treated accordingly

2.

Non-haemorrhagic shock
a.
b.
c.
d.

Cardiogenic shock
Tension pneumothorax
Neurogenic shock
Septic shock

HAEMORRHAGIC SHOCK IN DETAIL

Most common cause of shock in trauma patients. NB shifts of fluid among fluid
compartments complicate management, as may the severity, time span and
resuscitative interventions.
Definition of haemorrhage
Haemorrhage is acute loss of circulating blood volume. Normal adult blood
volume is ~7% of body weight, therefore a 70kg man has a circulating blood volume
of ~5L. In children blood volume is calculated as 8-9% of body weight.

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Direct effects of haemorrhage

Classification of haemorrhage is based upon % of acute blood loss. On an individual
basis the differences between classes may not be apparent, however volume
replacement should be directed by the response to initial fluid therapy rather
than by relying solely on the initial classification. The classification is useful at
emphasising the early signs and Pathophysiology of the shock state.
It is dangerous to wait until the trauma patient precisely fits a physiological
class of shock before initiating aggressive volume restoration. Fluid
resuscitation must be initiated when early signs and symptoms of blood loss
are apparent or suspected, not when the BP is falling or absent.
Table 1
ESTIMATED FLUID AND BLOOD LOSSES
Based on patients initial presentation (based on a 70kg male)
Class I
Up to 750

Class II
750-1500

Class III
1500-2000

Class IV
>2000

Blood loss
(% blood
volume)
Pulse rate

Up to 15%

15-30%

30-40%

>40%

<100

>100

>120

>140

Blood
pressure
Pulse
pressure
(mmHg)
Respiratory
rate
Urine output
(mL/Hr)
CNS/Mental
status
Fluid
replacement
(3:1 Rule)

Normal

Normal

Decreased

Decreased

Normal or
Increased

Decreased

Decreased

Decreased

14-20

20-30

30-40

>35

>30

20-30

5-15

Negligible

Slightly
anxious
Crystalloid

Mildly
anxious
Crystalloid

Anxious,
confused
Crystalloid
and blood

Confused,
lethargic
Crystalloid
and blood

Blood loss
ml

INITIAL MANAGEMENT OF HAEMORRHAGIC SHOCK

Diagnosis and treatment of shock must be performed almost simultaneously
usually assuming initially that the cause is hypovolaemia. The basic principle is to
stop bleeding and replace the volume loss.
A.

Physical examination

Begins with immediately diagnosing life-threatening injuries including assessment of

ABCDEs. Baseline values for: vital signs, urine output and GCS must be gained to
monitor the patients response to therapy.
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1. Airway and Breathing take priority

2. Circulation haemorrhage control. Includes direct pressure to bleeding
site, assessment of perfusion and may require operative intervention to
control internal bleeding
3. Disability neurological examination
4. Exposure complete examination. NB prevent hypothermia
5. Gastric dilation Decompression with NG tube to reduce risk of aspiration
of gastric contents
6. Urinary catheter insertion to allow assessment of urine output (renal
function) and to check for haematuria.
B.

Vascular Access Lines

Venous access must be gained promptly best done with 2, 16G(minimum)

peripheral IV cannulae (short large cannulae are best for rapid fluid administration)
usually cited in the antecubital fossa or forearm in adults.
As IV lines are started blood should be drawn for: Type, Cross match, FBC, U&E,
Toxicology (if appropriate) and in all females of child bearing age pregnancy.
Arterial blood gas analysis should also be gained
C.

Initial fluid therapy

Isotonic crystalloid solutions are used for initial resuscitation provides transient
intravascular expansion and further stabilises vascular volume by replacing
accompanying fluid losses into interstitial and intracellular spaces.
An initial fluid bolus is given as rapidly as possible. The usual dose is 1 to 2 L
(adults) and 20mL/kg (paediatric). The patients response is then used to judge
further therapeutic and diagnostic decisions.
The amount of fluid and blood required for resuscitation is difficult to predict
during the initial patient evaluation. Table 1 is used to provide general guidelines
for establishing the amount of fluid and blood the patient is likely to require.
The 3 for 1 rule is used based on 3L of crystalloid fluid needed to replace each
litre of blood lost (including loss to the interstitial and intracellular spaces). It is also
essential to look for evidence of adequate end-organ perfusion and oxygenation
based upon urine output, level of consciousness, and peripheral perfusion.
Reassessment is needed if fluids needed greatly exceed estimates of fluid
anticipated.
EVALUATION OF FLUID RESUSCITATION AND ORGAN PERFUSION
A.

General

Signs and symptoms of inadequate perfusion are the same as those used for shock
in assessing patient response i.e. normal BP, pulse pressure, pulse rate. NB they do
not indicate organ perfusion, which requires us to look at CNS status and skin
circulation (difficult to quantitate).

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Urine output is a good indicator of adequate renal perfusion and is a prime monitor of
resuscitation and patient response. Consideration should be given to measurement
of central venous pressure via a Swan-Ganz catheter (NB associate risks).
B.

Urine Output

Within limits used to monitor renal blood flow. Adequate volume replacement
generates approximately 0.5mL/kg/hr in adults (1mL/kg/hr for paediatric
patients)
C.

Acid/Base Balance

Should also be monitored but routine use of Sodium bicarbonate is not indicated to
treat metabolic acidosis secondary to hypovolaemic shock.
THERAPEUTIC DECISIONS BASED UPON RESPONSE TO INITIAL FLUID
RESUSCIATION
The patients response to initial fluid therapy is the key to determining
subsequent therapy. It is particularly important to distinguish the patient who is
haemodynamically stable (may have persistent tachycardia, tachypnoeic, and
oliguric still underresuscitated) compared with haemodynamically normal
(adequate signs of tissue perfusion).
Response patterns may be rapid response, transient response and minimal or no
response to initial fluid therapy (see table 2).
Table 2
RESPONSES TO INTIAL FLUID RESUSCITATION
Rapid response

Transient
response
Transient
improvement;
recurrence of BP
& HR
Moderate and
ongoing (20-40%)
High

No Response

Low
Type and
crossmatch
Possibly

Moderate to high
Type-specific
Likely

Immediate
Emergency blood
release (O-neg)
Highly likely

Yes

Yes

Yes

Vital signs

Return to normal

Estimated
blood loss
Need more
crystalloid
Need for blood
Blood
preparation
Need for
operative
intervention
Early presence
of surgeon

Minimal (10-20%)
Low

Remain abnormal

Severe (>40%)
High

Table base upon 2000mL Ringers lactate solution in adults, 20mL/kg Ringers
lactate bolus in children

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BLOOD REPLACEMENT
The decision to give blood is based on the patients response, as illustrated in table
2.
A.

Packed RBC vs Whole Blood

Either may be used to resuscitate a trauma patient, however component therapy is

usually used (to maximise blood products available). The main purpose of
transfusing blood is to restore the O2 carrying capacity of the intravascular
volume. Crystalloids can be used for volume replacement itself.
B.

Crossmatched, Type-specific and Type O blood

i. Full crossmatching is preferable NB takes ~ 1hour and is used in patients who

stabilise rapidly and be available if necessary.
ii. Type specific blood available ~ 10minutes. ABO and Rh compatible but other
incompatibilities may exist. Blood product of choice in transient responders and
crossmatching should be completed by the blood bank.
iii. O neg blood used in cases of exsanguinating haemorrhage where one
cannot wait for type specific blood. Also used when treating multiple casualties
because no risk of accidental wrong patient administration.
C.

Warming fluids Plasma and Crystalloid

Hypothermia must be prevented and reversed if the patient is hypothermic on

arrival at hospital. This may be most effectively achieved by warming crystalloid
fluids to 39C by means of a warmer or microwave oven.
SUMMARY
Shock management, based on sound physiological principles is usually successful.
Hypovolaemia is the cause of shock in most trauma patients. Management of these
patients requires immediate haemorrhage control and fluid or blood replacement. In
patients who fail to respond to these measures, operative control of ongoing
haemorrhage (by a surgeon) may be necessary. Other possible causes of shock
must also be determined. The patients response to initial fluid therapy determines
further therapeutic and diagnostic procedures. The goal of therapy is prompt
restoration of organ perfusion with delivery of oxygen and substrate to the cell for
aerobic metabolism.

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