# Titration for normal saline



## rhan101277 (Jul 22, 2009)

How difficult is it to titrate to keep blood pressure up on someone in hemmorhagic shock?  I would think just run it wide open.  

What if its something less serious.  Does that come with experience?

Also what about giving drugs to folks un-responsive.  Do you just ask family members how much they weigh, if they are alone do you just make a guess?


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## rescue99 (Jul 22, 2009)

You could ask. Otherwise we guestimate weights. After a while ya get pretty good at it.


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## rhan101277 (Jul 22, 2009)

After you guestimate and titrate then you just check BP to make sure its going up.

Also what about giving to low of a dose if you guestimate isn't right for the other drugs?


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## rescue99 (Jul 22, 2009)

Fluids are directly related to the patient's needs and history. Boluses of fluid for someone a quart low could be given 200cc at a time up to 20cc/kg for in an adult. In some cases, a liter bolus is okay then back off and monitor for the need for any additional. Vitals have to be monitored closely when administering volume fluids so check often!


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## rescue99 (Jul 22, 2009)

Well, if ya don't have an exact, the best we can do is take a stab at a person's weight. 
Just do your best. Rounding down on doses is generally safer however, with some can go a bit higher and not present a problem. Its a good thing all meds aren't dosed by weight, eh?


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## medic417 (Jul 22, 2009)

And while titrating monitor EKG, Lung and Heart sounds, skin appearance, pulse, etc, etc, etc as you can over do and do more harm than good.  Plus many references now indicate the need to limit the amount of fluids to avoid causing the bleed from getting bigger.


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## 8jimi8 (Jul 22, 2009)

For hemorrhagic shock, our protocols call for "permissive hypotension." The rationale behind this is to infuse just enough fluid to maintain LOC and perfusion to vital organs.  If someone is bleeding out, increasing their pressure too much is going to cause them to bleed more.  One thing that the 0.9% NS, or LR is giving is volume, one thing that it is not giving back to the patient is hemoglobin.  Also, by increasing pressure too much, you may break clots that are forming.  So you see, it is not just about getting two 14 gauge catheters and just turning it to wide open and giving them a bp of 130/80.


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## thrilla82 (Jul 22, 2009)

just as the above post states, you need to stay concerned about keeping organs operating and not busting clots with too much fluid.  another down fall to .9 or lr is that only so much gets absorbed into the venus system.  a lot of that fluid stays outside the veins.  depending on the time with the pt, you can end up causing edema and preventing a clot from forming.  theres other fluids you can play around with too, like hextend and hespen.  just make sure you titrate very carefully with those cause you can only give so much.  a good rule of thumb we use in combat medice is, if they have a radial pulse, saline lock.  if not, titrate fluid til one is confirmed.


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## ResTech (Jul 22, 2009)

As others have already said, to estimate weight of a patient you just take a SWAG (scientific wild *** guess).. ha ha... or ask the patient if they are conscious or ask a family member. Estimation is all you can do. 

To echo what's already been mentioned, with hemmorhagic shock, the goal is to maintain a pressure sufficient for perfusing the organs.... generally in the range of 90-100mmHg. Science has found that the body does in fact have a protective mechanism in place that kicks in during low-flow states to preserve the body's organs.... research shows this to be true even at pressures of 70-80mmHg. 

Large volumes of fluid can raise a pressure higher than it needs to be which can break clots, dilute clotting factors making it harder on the body to stop bleeding, and increase the rate of exsanguination.  

A general rule of replacement is 3mL of fluid for every 1mL of blood loss (a 3:1 ratio) or 20cc/kg up to a total of 2,000mL prior to consult (Maryland protocol) for adults.  

Less than 25% of infused crystalloid fluids remain intravascular after the first hour.


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## Shishkabob (Jul 22, 2009)

ResTech said:


> or ask the patient if they are conscious



"Excuse me sir... are you conscious?"


^_^


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## wyoskibum (Jul 23, 2009)

rhan101277 said:


> How difficult is it to titrate to keep blood pressure up on someone in hemmorhagic shock?  I would think just run it wide open.



Unless you have some crazy long transport times, you're not going to infuse that much fluid even running wide open.



rhan101277 said:


> Also what about giving drugs to folks un-responsive.  Do you just ask family members how much they weigh, if they are alone do you just make a guess?



I try to get the actual weight whenever possible.  Otherwise I look at my patient and decide if they are SM, MED, LRG, or XL.  More like an educated guess.

SM   +/- 100 lbs
MED +/- 150
LRG  +/- 200
XL     >   250


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## Melclin (Jul 23, 2009)

Just like any other skill, it is not difficult to stick a cannula in and run some fluids up to a predefined BP, but it's significantly harder to actually tailor medical treatments to each pt. I know this comes up alot, this whole education thing. I don't mean to be one of these guys who says you won't be able to properly treat a pt until you get you're masters, but volume management is still a difficult issue for any level of healthcare professional. There is no definite consensus on prehospital fluid resus, so at the very least, get stuck into the evidence out there, don't just crack a text book, although that's a good place to start.


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## 46Young (Jul 23, 2009)

Our protocls are simple, for blunt trauma, titrate for BP of 90 systolic. For penetrating trauma, titrate to 70 systolic. Max 1 Liter NS. Txp times are short, and we have medevac available if need be, weather permitting.


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## paccookie (Jul 28, 2009)

wyoskibum said:


> Unless you have some crazy long transport times, you're not going to infuse that much fluid even running wide open.
> 
> 
> 
> ...



I have infused 1200 cc in 15 minutes with an 18 gauge and a 20 gauge.  But that pt was hyperglycemic, not trauma.  I agree with the permissive hypotension suggestions.  Unless you have crazy long transport times to any hospital, you're probably not going to need that much fluid.  Just run in enough to maintain CPP if head trauma or around 90 systolic for other trauma.  I have given trauma pts a liter on the way to the hospital, but not too often.  Our level I is about 15-20 minutes away and our regular hospital is about 5-10 minutes away, so transport times are rarely an issue unless extrication is involved.


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