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Includes the Adobe Acrobat Reader for reading and printing publications.
Numerous illustrations and matrices.
Contains the following key public domain (not copyrighted) U.S. Government publication(s) on one CD-ROM in both Microsoft PowerPoint and Adobe Acrobat PDF file formats:
TITLE: Hypovolemic Shock Management, 67 pages
SLIDE TOPICS, SUBTOPICS and CONTENTS:
Hypovolemic Shock Management Introduction Basic life-saving steps for the soldier medic include: A-B-Cs. Shock and fluid resuscitation. Fluid Resuscitation Control hemorrhage first. Casualties with significant injuries should have a single 18 ga IV with saline lock in a peripheral vein initiated. Casualties without significant injuries do not need an IV but should be encouraged to drink fluids. Saline Lock Kit Saline Lock Saline Lock Saline Lock Saline Lock Saline Lock Fluid Resuscitation If unable to start a peripheral IV consider initiating a sternal I/O.
Intraosseous Access Sternal vs. tibial. Majority of wounds are extremity wounds (> 60%). Tibial cortex is very thick. Sternum protected by body armor. Sternum is uniform from person to person.
Intraosseous Access Indications: Inadequate peripheral access Need for rapid access for medications, fluid or blood Failed attempts at peripheral or central venous access Intraosseous Access Typical protocol precautions: F.A.S.T.1 not recommended if: Casualty is of small stature: Weight is less than 50 kg. Pathological small size Fractured manubrium/sternum - flail Significant tissue damage at site Severe osteoporosis Previous sternotomy and/or scar Flow Capabilities 30 ml/min by gravity. 125 ml/min utilizing pressure infusion. 250 ml/min using syringe forced infusion. Administering Blood Blood is 4 times more viscous than NaCl. Result is 1/4 normal rate of flow when administering blood using gravity. Infusion catheter internal pressure during gravity infusion = ~75 mmHg. Catheter can take up to 1,500 mmHg. Solution? Use pressure infusion
F.A.S.T.1 is considered a short-tem device and should not to be left in place for > 24 hours.
Perpendicular Insertion F.A.S.T.1 must be inserted perpendicular to the surface of the manubrium. Device penetrates bone only 6 mm. Perpendicular relationship to the surface of the manubrium critical for catheter to enter marrow space. Rich vasculature drains manubrium… F.A.S.T.1 is equivalent to a peripheral IV. Perpendicular Insertion Confirm landmarks:
Manubrium is upper aspect of sternal structure
Articulates with body of sternum at the “Angle of Louis” Perpendicular Insertion Note that there are three planes relative to the casualty: 1-Surface of ground 2-Surface of body of the sternum 3-Surface of the manubrium Perpendicular Insertion Manubrium surface angle is your point of focus. Perpendicular means at right angles to the surface of the manubrium. F.A.S.T.1 Procedure Procedure: Prepare site using aseptic technique Betadine Alcohol F.A.S.T.1 Procedure Insertion: Finger at suprasternal notch Align finger with patch indentation Emplace patch F.A.S.T.1 Procedure Insertion: Place introducer needle cluster in target area Assure firm grip Introducer device must be perpendicular to the surface of the manubrium F.A.S.T.1 Procedure Insertion: Insert using increasing pressure till device releases (~20-30 pounds) NOTE: If more force than that is needed, it’s not perpendicular) Maintain perpendicular alignment to the manubrium throughout F.A.S.T.1 Procedure Insertion: Following device release, infusion tube separates from introducer Remove introducer by pulling straight back Cap introducer using post-use cap supplied F.A.S.T.1 Procedure Insertion: Connect infusion tube to tube on the target patch Assure patency by use of syringe administer 5 ml blast of saline Clears any tissue debris in the infusion catheter F.A.S.T.1 Procedure Insertion: Connect IV line to target patch tube Open IV and ensure good solution flow F.A.S.T.1 Procedure Insertion: Emplace the dome over the site F.A.S.T.1 Procedure Insertion: Be certain that remover device is attached to (and transported with) the casualty F.A.S.T.1 Procedure Problems areas: Infiltration - usually due to insertion not being perpendicular to the manubrium Inadequate flow or no flow - Infusion tube occluded 1 ml saline flush recommended Infusion catheter inserted at other than a perpendicular angle to the manubrium surface F.A.S.T.1 Procedure Removal procedure: Stabilize target patch with one hand Remove dome with the other F.A.S.T.1 Procedure Removal procedure: Terminate IV fluid flow Disconnect infusion tube F.A.S.T.1 Procedure Removal procedure: Hold infusion tube perpendicular to the manubrium Maintain slight traction on the infusion tube Insert the remover while continuing to hold infusion tube in slight traction F.A.S.T.1 Procedure Removal procedure: Advance remover THIS IS A THREADED DEVICE Gentle counterclockwise movement at first may help in seating remover Make sure you feel the threads seat F.A.S.T.1 Procedure Removal procedure: Turn it clockwise until remover no longer turns This firmly engages remover into metal (proximal) end of the infusion tube
F.A.S.T.1 Procedure Removal procedure: Remove infusion tube Use only “T” shaped knob and pull perpendicular to the manubrium Hold target patch during removal DO NOT pull on the Luer fitting or the tube itself F.A.S.T.1 Procedure Removal procedure: Remove target patch F.A.S.T.1 Procedure Removal procedure: Dress infusion site using aseptic technique Dispose of remover and infusion tube using contaminated sharps protocol F.A.S.T.1 Procedure Removal procedure: Problems encountered during removal Performed properly…should be none! Be certain threads on remover engage threads at distal end of infusion catheter Moving remover around with tip as axis while in the infusion catheter may shear off end of removal tool F.A.S.T.1 Procedure Removal procedure: If removal fails or proximal metal ends separates: Anesthetize with local - make small incision Remove using clamp and close as appropriate NOTE: This is “serious injury” as defined by the FDA and is a reportable event Intravenous Solutions Different types of IV fluids can be used for different medical conditions
Generally categorized as: Colloid or Crystalloid
Colloids Contain protein, sugar or other high molecular weight molecules; used to expand intravascular volume. Whole blood (most common) Packed red blood cells Fresh frozen plasma Plasma Protein Fraction Hypertonic Saline & Dextran (HSD) Hextend is a 6% hetastarch solution in a balanced electrolyte solution
Crystalloids Solutions that do not contain protein or other large molecules; sodium is the primary osmotic agent. These fluids do not remain in the vascular system very long. Normal Saline (NS, 0.9% NaCl) Lactated Ringers (LR)
Fluids Fluid distribution. Intracellular space = 2/3 of body weight. Extracellular space = 1/3 of body weight. Interstitial space 80% Vascular space 20% Fluids 1,000 ml of Ringers Lactate (2.4 lbs) will expand the intravascular volume by 200-250 ml within 1 hour.
Why only 200-250 ml left?
Sodium diffuses out of the blood vessels into the extravascular (interstitial) space rapidly. Hextend 500ml of Hextend® weighs 1.3lbs will expand the intravascular volume by 800ml within 1 hour, and will sustain this expansion for 8 hours.
How does this happen?
Large sugar molecule-pulls fluid from the extra vascular (interstitial) space into the vessels.
Fluids One liter of Hextend = 6-8 liters of RL. Is it a better resuscitation fluid? No, it is better for hypovolemia because of its weight and cube advantage for the soldier medic. Ringers lactate is better for dehydration. Soldier medics must carry some of each. Resuscitation Indicators How do you determine who needs fluids? Blood Pressure. Peripheral (radial) pulse. Can BP be measured in a combat environment? Helicopters Tracks Battlefield conditions
Hypotensive Resuscitation Casualties should only be resuscitated to a blood pressure of 80 mmHg.
If blood vessels have clotted can you raise the blood pressure high enough to pop the clot off?
YES at a BP of @ 93 mmHg Resuscitation Indicators The systolic blood pressure may be approximated by palpating specific pulses:
Palpable carotid pulse = 60 mmHg Palpable femoral pulse = 70 mmHg Palpable radial pulse = 80 mmHg Fluid Resuscitation Superficial wounds (>50% injured); no immediate IV fluids needed. Oral fluids should be encouraged. Fluid Resuscitation Any significant extremity or truncal wound (neck, chest, abdomen, pelvis).
If the casualty is coherent and has a palpable radial pulse (BP 80 mmHg), initiate a saline lock, hold fluids and reevaluate as frequently as the situation permits. Fluid Resuscitation If casualty has a palpable radial pulse, why initiate a saline lock?
By establishing intravenous access now, when they have an adequate BP, it is easier than when they have a lower/absent BP. Fluid Resuscitation Significant blood loss from any wound, and the soldier has no radial pulse or is not coherent -STOP THE BLEEDING- by whatever means available - tourniquet, direct pressure, hemostatic dressings, or hemostatic powder etc.
Start 500 ml of Hextend®. If mental status improves and radial pulse returns, maintain saline lock and hold fluids. Fluid Resuscitation If no response is seen give an additional 500 ml of Hextend® and monitor vital signs. If no response is seen after 1,000 ml of Hextend®, consider triaging supplies and attention to more salvageable casualties.
Why? Resources: How many more casualties do you have and how much fluid is available? Fluid Resuscitation If casualties are not resuscitated with 1,000ml of Hextend they are probably still bleeding. If excess fluids are given they will die faster than a casualty who received no fluids.
Why? Increased BP and coagulation factors diluted as BP rises hemorrhage increases
Why then does ATLS recommend 2 large-bore IVs and fluid run wide open? The transit time to definitive care is only a few minutes.
Why does hypothermia happen? Hypothermia Casualties who are hypovolemic quickly become hypothermic. Body temperatures below 91° F causes the vicious triad. Hypothermia Acidosis Coagulopathy Hypothermia When this vicious triad occurs the casualty’s blood will not clot.
Prevention is the best method. Field Expedient Warming Hypothermia Prior to evacuation, casualties must be wrapped in a blanket to prevent heat loss during transport (even if the temperature is 120° F) especially true with air evacuation Hypothermia Prevention and Management Kit™ Hypothermia Prevention and Management Kit™ (HPMK) Ready for Transport
Summary Identify hypovolemic shock.
Ensure hemorrhage control first.
Provide treatment for hypovolemic shock using hypotensive resuscitation principles. Questions?
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