Crystalloid in trauma hypovolemic shock?

[STXmedic]

Hey,

I'm new in this forum. Can anyone write out the types of the infusions please? Because it's not easy for one from Germany. ;-) thank you!

Not exactly sure what you're asking for. Are you asking for the types of IV fluids that can be infused?

 

[Worminger]

Not exactly sure what you're asking for. Are you asking for the types of IV fluids that can be infused?

I mean, what is the meaning of the abbreviations LR or NS. Maybe lactate ringer? I dunno

 

[MonkeyArrow]

I mean, what is the meaning of the abbreviations LR or NS. Maybe lactate ringer? I dunno

NS is normal saline AKA 0.9% sodium chloride solution, and LR is lactated ringers.

 

[Worminger]

NS is normal saline AKA 0.9% sodium chloride solution, and LR is lactated ringers.

Thank you very much ;-)

 

[Brandon O]

LR is lactated ringers.

Possibly known as Hartmann's solution in your part of the world.

 

[TransportJockey]

PHTLS 8th edition. page 221

As a PHTLS instructor, what they teach in class and best practice for your patient are often miles apart.

 

[richie101883]

Ringer def better for blood loss to 80/90 systolic

 

[Carlos Danger]

Ringer def better for blood loss to 80/90 systolic

Citation?

 

[VentMonkey]

Great post Remi, I have learned a lot from many of your posts. To kind of echo what you have already stated, to my knowledge it doesn't much matter which crystalloid we use in the prehospital arena when it comes to trauma. Perhaps burns, then yes LR seems more fitting given its contents.

For us in the field, I don't see many providers needing to worry much about rapid infusion of mass amounts of NS or LR anyhow for the trauma patient. After about 2 liters we're merely diluting their blood volume further, and increasing morbidity and/ or mortality. At this point these patients would probably (hopefully) be in the resus bay receiving blood product, and being prepped for surgery.

Sometimes I think we tend to way overthink something as simple and straightforward as prehospital trauma management at the ALS level.

 

[VFlutter]

Doesn't matter much at all.

Large volumes of NS result in a lower pH and possibly a hyperkalemia. Some studies show more tendency towards coagulopathy, as well.

However, my understanding is that studies have shown no difference in mortality. So it's one of those things where the numbers might make you feel better, but the eventual outcomes are the same.

So most of us will use LR, because it does look better on paper. But if someone is bleeding bad enough to need large volume resuscitation, the only thing that really helps is blood.

Moderator Note: Changed NS to LR per user's request.

I often wondered if we were doing more harm than good resuscitating these patients with crystalliod. Most uncomplicated trauma patients, without major comorbidities, can tolerate pretty substantial shock and recover. Just look at patients with prolonged cross clamp times in the OR. However, once these patients are over-resuscitated and become hypothermic, hyperchloremic, acidotic, and coagulopathic there isn't much you can do to keep them from spiraling when they might have just been better off being shocky for a little bit before going to the OR.

 

[Carlos Danger]

I often wondered if we were doing more harm than good resuscitating these patients with crystalliod. Most uncomplicated trauma patients, without major comorbidities, can tolerate pretty substantial shock and recover. Just look at patients with prolonged cross clamp times in the OR. However, once these patients are over-resuscitated and become hypothermic, hyperchloremic, acidotic, and coagulopathic there isn't much you can do to keep them from spiraling when they might have just been better off being shocky for a little bit before going to the OR.

Yep.
My understanding is that common practice in the military field hospitals is no fluids at all until you have blood available - no matter how low the BP is - and even then only enough to maintain a pulse, until bleeding is controlled. And despite the severity of the trauma that they see, their outcomes are better than civilian trauma centers.

 

[Summit]

Yep.
My understanding is that common practice in the military field hospitals is no fluids at all until you have blood available - no matter how low the BP is - and even then only enough to maintain a pulse, until bleeding is controlled. And despite the severity of the trauma that they see, their outcomes are better than civilian trauma centers.

I'd believe it was an effect of their treatment, but I also must point out that their patients are typically younger and far healthier than urban trauma patients.

 

[HMartinho]

In our system, we use (and abuse) in NS and LR, specialy if systolic BP <90 mmHg

Plasmalyte its pretty rare in trauma situations.

 

[E tank]

Normosol or plasmalyte have a pH of (about)7.4 so using those for large volumes of crystalloid replacement makes more intuitive sense in a patient that is at risk for metabolic acidosis. But we're talking about trauma here so smaller volumes of crystalloid are appropriate if used much at all before blood. Two liters of any isotonic solution is as good as any other in that situation, but the sooner blood goes in and less crystalloid, the better.

 

[VentMonkey]

Normosol or plasmalyte have a pH of (about)7.4 so using those for large volumes of crystalloid replacement makes more intuitive sense in a patient that is at risk for metabolic acidosis. But we're talking about trauma here so smaller volumes of crystalloid are appropriate if used much at all before blood. Two liters of any isotonic solution is as good as any other in that situation, but the sooner blood goes in and less crystalloid, the better.

This is what's been emphasized with pretty much any, and every CCP course I have gone through thus far.

 

[E tank]

This is what's been emphasized with pretty much any, and every CCP course I have gone through thus far.

Right...and we should all be aware that things change pretty dramatically in relatively short periods of time. Within my career, we've come from aggressive pre-hospital crystalloid resus of trauma related hypotension to permissive hypotension and blood. Everything with a grain of salt...

 

[VentMonkey]

Right...and we should all be aware that things change pretty dramatically in relatively short periods of time. Within my career, we've come from aggressive pre-hospital crystalloid resus of trauma related hypotension to permissive hypotension and blood. Everything with a grain of salt...

Clearly, EBM, and a proactive approach to the ever changing dynamics of medicine in general goes without saying.

 

[E tank]

Clearly, EBM, and a proactive approach to the ever changing dynamics of medicine in general goes without saying.

Right...that's what they said 30 years ago