Fluid Therapy
 

The vast majority of trauma patients (with the exception of cirrhotic patients or severe alcoholics) are hyperglycemic and should not be given glucose with the resuscitation fluids.

Re: Fluid Therapy
 

So guys with Cirrhosis tend to be hypoglycemic, how does one ascertain this from someone who is "out of it"? Not sharpshooting, merely interested:

If I help Nancy consume our approx 8000 bottles of red wine, plus her single malt collection, and my Tequila collection, I may very likely fall into that category:;)

Terry

Re: Fluid Therapy
 

\

why are they typically hyperglycemic and is the glucose level prognostic or just an interesting fact?

doc t

Re: Re: Fluid Therapy
 

LOL - in a bad mood?

I'm going to say its part of stress hypermetabolism characterized by substantial increases in metabolic rate, oxygen consumption, and production of carbon dioxide and heat. Energy requirements are amplified by 30% to 50%4 to support inflammation, immune function, and tissue repair.

Yes, its prognostic. There are studies that show increased morbity and sepsis associated with hyperglycemia associated with trauma.

How'd I do?

in a good mood actually... got to spend part of the day with my daughters doing important things like going and seeing Dragon Tales (and dragging aprofsold with me)

but back to the question at hand...

you did well...lol... glucose goes up for a multitude of reasons due to the stress response with alot of anti-insulin type of hormones being secreted... epinephrine, glucagon and especially cortisol. All promote gluconeogenesis and overwhelm a system that is already being overwhelmed on too many fronts.

and yes, recent studies are coming out that it is prognostic as is glucose control during hospitalization.

doc t.

Re: Fluid Therapy
 

Who gives glucose with fluid unless the trauma was a direct result of being hypoglycemic?

James D

Re: Re: Fluid Therapy
 

you would be surprised what outside facilities transfer patients on...

doc t.

Re: Re: Re: Fluid Therapy
 

Come on now...

Outside facilities being smaller ER's?

I have yet to find a useful purpose for D5, D5-1/2 NS, D5-LR on a trauma out here in the street or in a Bay for that matter, but then again...

Re: Re: Re: Fluid Therapy
 

No he wouldn't, he's one of them! LOL

Re: Re: Re: Re: Fluid Therapy
 

When you are deep in the woods, out of water, and really thirsty, the D5W tastes better than the NS.

I drank from a bag of RL one time while trotting around the desert looking for a big blue square of cloth I lost when I pulled a little red thingy on my parachute.

It tasted pretty bad. Of course no telling how long it had been laying out there.

Re: Re: Re: Re: Fluid Therapy
 

Hardy-har-har.

Re: Re: Re: Re: Re: Fluid Therapy
 

Maybe I should have worded that differently and added, "in the prehospital setting."

I can imagine it would be better than NS though.

What degree of blood loss is required to induce hypotension?

Loss of as little as 1/5th of circulating volume can cause Hypovolemia.

do all cases of hypovolemia cause hypotension? This leads into the 4 classes of shock and the symptoms of each...

guess that is the homework of the evening...

easy enough to find... amount of blood loss, percent of circulating volume, HR, RR, BP, pulse pressure, mental status, urine output and resuscitation for each...

post either here or the shock folder...

(I am intruding as usual)

doc t.

Intruding? No way. I'll work on it tomorrow if Cric boy doesn't beat me to it.

4 Types of Shock
 

CARDIOGENIC: When the heart fails to pump enough blood.
Causes: MI when 40-50% of the myocardium is destroyed, or secondary to valve dysfunction or cardiomyopathies or cardiac arrest
S/S: Increased workload on ventricles from catecholamine release; Restlessness; weakness; alterations in mentation; Decreased urine output (oligouria); Alterations of peripheral perfusion; pallor; cyanosis; Tachycardia; hypotension; dysrhythmias; Deteriorated pulmonary status (congestion and/or edema) and eventually Cardiac arrest
TX: CPR and follow ACLS protocols, Vasopressors and diuretics, Intra-aortic balloon device or ventricular assist devices, Heart transplant

HYPOVOLEMIC: When volume of bloods loss is enough to inhibit tissue perfusion.
Causes: Hemorrhage, Vomiting and diarrhea, Burns, third space fluid loss.
S/S:
Mild: Volume loss is 10%;CO is decreased and SNS is activated; Skin is pale, cool and clammy; Mucosa is mildly dry; Skin turgor is decreased; Anxiety, restlessness, thirst, weakness
Moderate: Volume loss is 15-40%; CO and BP decrease dramatically; Tachycardia; tachypnea; pallor; Poor skin turgor; Thirst; restlessness; weakness; Decreased urine output
Severe: Volume loss exceeds 45%; Vital organ functions display effects of decreased perfusion; Decreased level of consciousness; confusion; agitation; Metabolic acidosis; and eventually death
TX: treat cause of loss and replace fluid loss 3:1 with an isotonic solution and packed RBC

DISTRIBUTIVE: When there is a loss is SVR.
Causes: Sepsis(TSS, SIRS), Neurological trauma, or Anaphylaxis from food, drugs, or insect stings
S/S:
Sepsis: Hypotension, Fever, Decreased CO, tachycardia, dysrhythmias, Clammy, pale skin, Pulmonary congestion, tachypnea
Anaphylaxis: Alterations in mentation; Urticaria; pruritus; Bronchoconstriction; tachypnea; wheezing; Warm and flushed skin;Tachycardia; angina; dysrhythmias; hypotension; Decreased CO
Neurologic: Alterations in LOC; Cool and clammy skin above lesion; Warm and dry below lesion; Bradycardia; Hypotension; Tachypnea
TX: IV fluids to fill container, Probably give vasopressors
Sepsis: ID and eliminate nidus of infection, ABX therapy
Anaphylaxis: benadryl 50mg IV, 1mg 1:10,000EPI IV(if patient is mearly having an allegic reaction .03mg 1:1000 EPI SQ)
Neurological: fix spinal dysfunction, steroids, vasopressors

OBSTRUCTIVE: When something permits the heart from pumping.
Causes: Cardiac Tamponade, Pneumothorax, or PE
S/S: b/p drop as tamponade becomes greater, pulse pressures narrow, Tachycardic, tachypnic, skin cool/clammy, LOC drops as CO decreases.
TX:
Cardiac Tamponade: Pericardialcentesis
Pneumothorax: Needle/tube Thorocotomy
PE: Systemic anticoagulation, possibly thrombolysis or surgical embolectomy.

those are the different types of shock...not the different classes but GREAT job....

now back to the drawing board for the real answer however....

doc t.:D

Dammit
 

Sorry DocT. Somehow when I read "Classes of shock" I thought 4 types of shock.

JD

no need to apologize... it is a great piece for on here... but the question Sneaky has asked (sorry, cannot remember all those initials) was about percentage of losses to achieve hypotension...

the classes of shock spell this out very well. If you cannot find it and Sneaky doesn't respond soon I'll post the stuff later when I have a moment...

doc t.

Try this again.
 

For a 70kg male

Class 1
Blood Loss(ml) <750
Blood Loss(%BV) <15%
Heat Rate <100
Pulse Pressure(mmHg) Normal
Repiratory Rate 14-20
Urine Output(ml/hr) >30
CNS/Mental Status Slightly anxious
Fluid Replacement Crystalloid

Class 2
Blood Loss(ml) 750-1500
Blood Loss(%BV) 15-30%
Heat Rate >100
Pulse Pressure(mmHg) Normal
Repiratory Rate 20-30
Urine Output(ml/hr) 20-30
CNS/Mental Status Mildly Anxious
Fluid Replacement Crystalloid

Class 3
Blood Loss(ml) 1500-2000
Blood Loss(%BV) 30-40%
Heat Rate >120
Pulse Pressure(mmHg) Decreased
Repiratory Rate 30-40
Urine Output(ml/hr) 5-15
CNS/Mental Status Anxious & Confused
Fluid Replacement Crystalloid & Blood

Class 4
Blood Loss(ml) >2000
Blood Loss(%BV) >40%
Heat Rate >140
Pulse Pressure(mmHg) Decreased
Repiratory Rate >35
Urine Output(ml/hr) Negligible
CNS/Mental Status Confused & Lethargic
Fluid Replacement Crystalloid & Blood

................................Class I.........ClassII.....ClassIII.....ClassIV
Blood loss(%).......... <15.............15-30.......30-40........>40
Blood Loss(ml) ..........<750.......750-1500...1500-2000..>2000
Pulse rate ...............Normal........100-110...120............>120
Systolic....................Normal.........Normal. ....Low...........Very Low
Diastolic...................Normal.........High... ......Low...........Very Low
Capillary Refill..........Normal.........Slow........Slow... ........Absent
Mental State............Alert.............Anxious...Confu sed...Lethargic
Resp. Rate...............Normal.........Normal.....Tachy .........Tachy
Urine Output............>30 ml/hr.....20-30......5-20 ml .....<5 mls/hr

***above reference is for average adult with no medicines that could alter baselines

much better..

but not sure your source...most charts show a drop in pulse pressure with Class II shock, and ultimately SBP drops in Class III shock...

so to answer Sneaky's question....

Class III shock would typically be the level to START seeing hypotension...or a 30-40% blood volume loss....

Didn't mean to double post your info James...
I was copying my old post while you typed that out.

It is from my paramedic notes. Albeit they are now 13 years old.

I somehow missed B/P in my chart. I have it here but somehow missed adding it.

James D

NP.

Welcome.

James D