Large volume resuscitation(1)

• Plan for this with every major trauma
• Minimum of 2 large bore IV’s
• Consider insertion of Rapid infusion device
• Choose technique most familiar with
• May need to call for extra expertise
• Choose access appropriate for injury
Eg femoral venous line unsuitable if suspect IVC/hepatic injury

Large volume resuscitation(2)

• Use all available resources
• Delegation
• Documentation
• Monitoring
• Communicate with blood bank frequently re blood product availability
• Blood warmer

Large volume resuscitation - Monitoring

• Adequacy of volume replacement assessed by:
HR, blood pressure, peripheral perfusion, cerebral perfusion(if awake), urine output
Supplemented by serial haematocrits, observation and measurement of ongoing blood loss +/- Invasive monitoring: ART, CVP
Systolic pressure variation Transoesophageal echocardiography if expertise/resources avialable
• Monitor temperature

Fluid resuscitation(1)

• Up to 1 litre blood loss (20% blood volume)
Replace with crystaloid(up to 20ml/kg) then colloid
Check haematocrit
Consider packed cells
• Up to 2.5 litre blood loss (50% blood volume)
Give packed cells
Check coagulation
Consider coagulation factors/platelet Tx
Monitor haematocrit

Fluid resuscitation(2)

• Over 2.5 litre blood loss:
Give packed cells urgently
Give coagulation factors/platelet Tx
Check electrolytes
Serial assessments of coagulation/haematocrit/platelet count
• Assess response to fluid resuscitation is important:
Assess effect on peripheral perfusion, HR, Urine output, BP

Response to fluid resuscitation

• Rapid response
< 20 % BV
No further ongoing bleeding
• Transient response
Probably losses are 20 -50% BV
Response to blood may identify those still bleeding & requiring rapid surgical intervention

Minimal or no response to volume resuscitation

• Consider:
Concealed bleeding
Tamponade, tension pneumothorax, embolism
Spinal cord injury
Cardiogenic cause
Sepsis
Age, Medications other Co-morbidities
• Repeat primary survey
• May require urgent surgical intervention