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Supplemental oxygen
Definitive airway
Endotracheal intubation/surgical airway
Ventilatory support
Peripheral line
Antecubital peripheral line
Two large-caliber (14–16 gauge) catheters
Short, large-caliber peripheral IV lines are preferred for rapid infusion of large volumes of fluid.
Rate of flow is proportional to the 4th power of the radius of the cannula and inversely related to the length (Law of Poiseuille).
Intraosseous (IO) access
The bone marrow of long bones has a rich network of vessels that drain into a central venous canal, emissary veins, and, ultimately, the central circulation, providing a noncollapsible venous access.
Advantages
Rapid access in patients with failed peripheral IV line
Intraosseous route has roughly the same absorption rate as intravenous route.
Under pressure, fluid can be infused up to 200 mL/min.
Any medications that can be given via IV can be given per intraosseous route.
Needle should be removed within 3–4 hours, but it can be maintained for 24–72 hours. In practice, IO needle should be removed once an alternative vascular access is obtained.
The levels of drugs, chemistries, and hemoglobin, as well as acid-base status, obtained from bone marrow are reliable predictors of serum levels.
Contraindications
Fracture at the sites of insertion
Relative contraindications
Infection at the insertion site
Inferior vena cava injury
Previous attempt on the same leg bone
Osteogenesis imperfecta
Osteoporosis
Complications
Subcutaneous or subperiosteal infiltration is most common complication.
Pressure necrosis of skin at insertion site
Epiphyseal growth plate injury in children
Fat embolism
Local hematoma
Compartment syndrome: if the needle passes through the opposite cortex, the infused fluid enters the muscle rather than the venous system.
Extravasation of hypertonic or caustic medications, such as sodium bicarbonate, dopamine, or calcium chloride, can result in necrosis of the muscle.
Local infection and osteomyelitis
Technique of IO access
Sites
Anteromedial aspect of the proximal tibia is the most common site, as it lies just under the skin and can be easily palpated and located.
Anterior aspect of distal femur: anterior midline 1-2 cm proximal to patella.
Superior iliac crest
Sternum
Proximal humerus at greater tuberosity
Steps of tibial IO access
Identify the tibial tuberosity.
Locate the bone 2 cm distal and slightly medial to the tibial tuberosity.
Support the flexed knee by placing a towel under the calf.
Prep and drape the patient using sterile technique.
If the patient is awake, inject local anesthetic (1% lidocaine) into the skin, into the subcutaneous tissue, and over the periosteum.
Insert the IO needle through the skin and subcutaneous tissue using automatic intraosseous device.
Automatic intraosseous devices
Quick and provides safe access
Deploys inject needles to a preset depth
Confirm the placement by aspirating bone marrow and connect the IV tubing.
Central venous access
Indications
Failed peripheral IV
Failed IO line
Need for medications that can only be delivered centrally (certain vasopressors)
Consider using a short, large-bore catheter (8.5 F introducer sheath) or a double- or triple-lumen 7 F catheter.
Locations
Femoral: least sterile
Subclavian: avoided in patients with coagulopathy
Internal jugular (IJ)
Complications
Correlate directly with number of sticks
Arterial puncture: femoral > IJ > subclavian
Hematoma: femoral > IJ > subclavian
Pneumothorax: subclavian > IJ
Use of ultrasound (US) guidance: increases first-attempt success, reduces access time, reduces carotid puncture in IJ access
Specific complications of femoral venous access
Deep vein thrombosis (DVT)
Arterial or neurologic injury
Infection
Arteriovenous (AV) fistula
Specific complication of subclavian/IJ venous access
Pneumothorax
Venous thrombosis
Arterial or neurological injury
AV fistula
Chylothorax
Air embolism
Limited use of crystalloids
Typically, normal saline (NS) or lactated Ringer’s (LR) is used for initial fluid resuscitation of the trauma patients.
NS and LR have equivalent effects on hemodynamics and oxygen metabolism during resuscitation.
Resuscitation with LR has more favorable effects on fluid overload in lungs, coagulation, and acid/base balance (pH).
Advanced Trauma Life Support (ATLS) recommends 1 L of crystalloid as the starting point for all fluid resuscitation.
In penetrating trauma with hemorrhage, aggressive fluid resuscitation should be delayed until bleeding is controlled.
Balanced resuscitation prevents complications due to a large volume of crystalloids.
Infusion of large volumes of crystalloids to achieve a normal blood pressure is not recommended. Complications from large-volume crystalloid resuscitation include:
Prolonged ventilator dependence.
Increased hospital length of stay in the adult blunt trauma population.
Acute lung injury.
Acute respiratory distress syndrome (ARDS).
Multiorgan dysfunction.
Abdominal compartment syndrome.
Surgical Site Infections.
Coagulopathy due to:
Dilution of coagulation factors.
Hypothermia due to fluid stored at room temperature.
Large volume of normal saline causes hyperchloremic acidosis.
Permissive hypotension:
Also known as hypotensive resuscitation and controlled resuscitation.
Goal mean arterial pressure (MAP) 40–50 mm Hg or systolic blood pressure (SBP) of 80–90 mm Hg.
Elevated BP causes more bleeding due to dislodgement of thrombus at the bleeding site.
Complications of prolonged permissive hypotension
Coagulation dysfunction
Ischemic organ dysfunction due to poor tissue perfusion
Mitochondrial dysfunction
Lactic acidosis
Contraindications of permissive hypotension
Patients with cerebrovascular disease, carotid stenosis, and compromised renal function
Patients with crush injury with rhabdomyolysis
Traumatic brain injury, and spinal cord injury. SBP >90 mm Hg is recommended in these patients.
Early use of blood and blood products
Early administration of red blood cells (including uncross-matched type O) to achieve a hematocrit of 25%–30%
Early use of plasma to maintain normal clotting factors
Use of cryoprecipitate in coagulopathic patients
Platelet transfusion if count <50,000
Use of a massive transfusion protocol (MTP) using a 1:1:1 product ratio or low-titer type O whole blood.
Use of goal-directed treatment of coagulopathy using viscoelastic assay
Advantages of balanced resuscitation over aggressive resuscitation
Reduces morbidity and mortality of trauma patients with hemorrhagic shock
Prevents lethal triad
Minimizes the impact of trauma-induced coagulopathy
Limits blood product waste
Reduces the complications associated with aggressive crystalloid resuscitation
Direct pressure on the bleeding wounds
Tourniquet
Local hemostatic agents
Pelvic stabilization
Pelvic binder
External fixator
Surgical hemostasis
External
Suture of bleeding laceration
Ligation of bleeding vessels
Control of bleeders with arterial clamps
Internal
Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)
Angioembolization
Resuscitative thoracotomy
Damage-control celiotomy
Lethal triad
Acidosis
Hypothermia
Coagulopathy
Not a fluid of choice for initial resuscitation
More expensive than crystalloids
Small risk of anaphylaxis
No significant advantages over crystalloids in the early stages of resuscitation
May be used in later part of resuscitation after a considerable capillary leak caused by the systemic inflammatory response syndrome (SIRS)
May be associated (but no strong evidence) with less peripheral and pulmonary edema due to less capillary leak
IV albumin does not have any advantage compared to crystalloid in resuscitation of hemorrhagic shock.
No role in survival of shock
May be indicated in pH <7.0
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