Thought we'd talk about some trauma stuff, specifically the resuscitation of the critically ill hemorrhagic shock patient.
There is much to discuss, so this will be a multi-episode affair.
Today, we'll concentrate on the Lethal Triad and BP Goals.
Lethal Triad
The picture says it all.
Bleeding causes acidosis, hypothermia, and coagulopathy. Then the cycle begins as they all beget each other. If this continues for too long, it is irreversible.
We can iatrogenically make things worse by keeping our patients exposed and infusing ice cold fluids and products. By diluting their existing clotting factors and platelets with too much fluid and red cells. And by not ensuring adeqaute perfusion to counter acidosis.
BP Goals
Your goal is a MAP of 65. This is not hypotensive resus, which is still not proven. It is normotensive resuscitation; beyond 65, no additional benefts will be seen, but you do risk increased bleeding and dilutional coagulopathy.
If MAP < 65 – give fluids/products
If MAP > 65 – check perfusion
there are monitors for this such as NIRS measurement of thenar eminence, but at this stage, I recommend using the presence of a nice strong pulse and warm hands.
MAP > 65 & Good Perfusion-stand tight
MAP > 65 & Bad Perfusion-give fentanyl 20-25 mcg
why fentanyl? b/c taking away pain and fear will limit endogenous catecholamines and the pt's bp will drop slightly from vasodilation. Now give fluids/products to take the MAP to > 65.
Here are the articles
resus of crit ill trauma patients
Next Time: Massive Transfusion Protocols
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Professor
Nassau University Medical Center
No conflicts of interest (coi).
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My trauma experience exactly what it feels like. My life is on pause. I have everything I need to thrive but cannot focus energy on any more than the bare minimum to survive. thanks for the blog
I would advise against redosing sux. There is a real risk of severe bradyarrythmias with repeated doses of sux. One of my college had and asystole with a second dose of sux with a 4 hour delay between doses (postpartum uterine revision under GA, four hours after c-section under GA). In pediatric anesthesia, it is very common to see bradycardia with succinylcholine. Some attending pretreat systematically with atropine before sux in peds. It is rare in adult in single dosing, but it happens. I would stick to an non-depolarizing neuromuscular blocking drug if the sux wears off. I don’t want… Read more »