Sun21November0420PM 13

A 19-year-old male is admitted to the Emergency Department with a suspected fractured pelvis.

Clinical examination is as follows:

Airway:

Patent

Breathing:

Respiratory rate 25 breaths per minute

Breath sounds vesicular, nil added

Circulation:

Capillary refill time of four seconds

Cool peripheries

Pulse 125 beats per minute

Blood pressure 125/96 mmHg

Disability:

Glasgow coma score 15

Anxious and in pain.

Secondary survey does not reveal any other significant injuries. The patient is given high flow oxygen therapy and intravenous access is established.

Which one of the following options is the most appropriate initial intravenous fluid regimen?

(Please select 1 option)

Crossmatched blood and products when available Correct

Regular boluses of 250 ml hypertonic saline

Immediate transfusion of four units of O -ve blood

Rapid infusion of Hartmann's solution to maintain a systolic blood pressure greater than 90mmHg

Rapid infusion of 1000 ml hetastarch

Explanation

The clinical signs suggest that 15-30% of circulating blood volume has been lost.

Pelvic fractures are associated with significant concealed haemorrhage (>2000 ml) and may require aggressive fluid resuscitation, initially with crystalloids and then blood. Other priorities include stabilisation of the fracture(s) and pain relief.

The Advanced Trauma Life Support (ATLS) classification of haemorrhagic shock is as follows:

Class I haemorrhage (blood loss up to 15%):

<750 ml of blood loss

Minimal tachycardia

No changes in blood pressure, RR or pulse pressure

Normally not require fluid replacement as will be restored in 24 hours, but in trauma correct.

Class II haemorrhage (15-30% blood volume loss):

Uncomplicated haemorrhage requiring crystalloid resuscitation

Represents about 750 - 1500 ml of blood loss

Tachycardia, tachypnoea and a decrease in pulse pressure (due to a rise in diastolic component due action of catecholamines)

Minimal systolic pressure changes

Anxiety, fright or hostility

Class III haemorrhage (30-40% blood volume loss):

Complicated haemorrhagic state in which at least crystalloid and probably blood replacement are required

Classical signs of inadequate perfusion, marked tachycardia, tachypnoea, significant changes in mental state and measurable fall in systolic pressure

Almost always require blood transfusion, but decision based on patient initial response to fluid resuscitation.

Class IV haemorrhage (> 40% blood volume loss):

Preterminal event patient will die in minutes

Marked tachycardia, significant depression in systolic pressure and very narrow pulse pressure (or unobtainable diastolic pressure)

Mental state is markedly depressed

Skin cold and pale

Need rapid transfusion and immediate surgical intervention.

Loss of >50% results in loss of consciousness, pulse and blood pressure.

Fluid resuscitation following trauma is a controversial area.

Whilst the clinical scenario points to a 15-30% blood loss at that point in time, further crystalloid and blood replacement may be required following an assessment of the clinical situation. However evidence is mounting to suggest that transfusion of large volumes of crystalloid in the hospital setting are likely to be deleterious to the patient and "hypotensive resuscitation" and judicious blood and blood product resuscitation is a more appropriate option. In adults a ratio of 1 unit of plasma to 1 unit of red blood cells to replace fluid volume.

This patient does not require immediate transfusion of O negative blood and there is time for a formal crossmatch. The colloid versus crystalloid argument has existed for decades; whilst they have a role in fluid resuscitation they are not first line.

Colloidal solutions are associated with anaphylaxis, hypernatraemia, and acute renal injury.

Answer Statistics

1

41%

2

2%

3

21%

4

38%

5

1%

Times answered: 264