Administer half the fluid in the first 8 hours following the injury, and the other half over the next 16 hours. IV fluids already administered should be deducted from the calculation. A urinary catheter should be inserted to guide fluid resuscitation, aim for a minimum urine output of 0.5 ml/kg/h in adults.
Further reading
Principles of management of major trauma
What is Damage Control Resuscitation?
Damage Control Resuscitation (DCR), also known as haemostatic resuscitation, aims to minimize the consequential ‘lethal triad’ of massive haemorrhage; acidosis, coagulopathy and hypothermia. DCR is often undertaken simultaneously with Damage Control Surgery; where control of immediately life-threatening injuries and major haemorrhage are addressed with definitive surgery delayed until physiological stability is achieved. For DCR to be most effective, hypovolaemic shock needs to be recognized early and resuscitation initiated immediately.
What are the three main principles of DCR?
The main principles of DCR are:
1. To avoid dilution coagulopathy, tissue oedema and impaired tissue oxygen delivery by minimizing administration of IV crystalloid during early resuscitation.
2. Permissive hypotension; aiming for a systolic blood pressure (BP) of 90 mmHg, to balance adequate tissue perfusion with allowing clot stabilization.
3. Transfusion of blood products in ratios similar to whole blood, approximately 1:1:1 of red blood cells, platelets and plasma. Massive transfusion should be guided by support from the massive transfusion policy/protocol, alongside support from haematology services. Coagulopathy should be recognized early and treated aggressively guided by rapid bedside dynamic assessment of coagulation and fibrinolysis such as thromboelastography (TEG) or thromboelastometry (TEM). There is no convincing evidence that use of recombinant factor VIIa improves outcomes in this situation.
What is the current evidence for use of tranexamic acid following significant haemorrhage due to major trauma?
The CRASH-2 trial was a randomized controlled trial of over 20 000 patients, published in 2010, which showed that administration of tranexamic acid (TXA) within 8 hours of injury (loading dose of 1 g over 10 minutes then infusion of 1 g over 8 hours) reduced all-cause mortality (relative risk 0.91, 95% CI 0.85–0.97). However, the number needed to treat was 121 patients and mortality increased when TXA was given more than 3 hours post injury. The investigators have recommended that TXA should not be administered more than 3 hours after the injury, and only in those who have severe haemorrhagic shock, with a systolic BP < 75 mmHg and a base deficit > 5, alongside hyperfibrinolysis demonstrated by TEG or TEM.
What is the current evidence for use of corticosteroid following head injury?
The MRC CRASH trial, published in 2005, was a near 10000 patient double blind placebo-controlled randomized trial which showed that administration of methylprednisolone post head injury increased the likelihood of death or serious disability up to 6 months following injury (odds ratio 1.15, 95% CI 1.07–1.24).
Further reading
Management of the patient with a fractured neck of femur
An 83-year-old lady was admitted 24 hours ago, with an intracapsular fracture of the left neck of femur following a fall at home. Her co-morbidities include hypertension, atrial fibrillation (AF) and asthma for which she is taking ramipril, bisoprolol, warfarin and inhalers. On preoperative assessment she has a Glasgow Coma Score (GCS) of 15/15, heart rate 99 bpm, blood pressure 142/89 mmHg and SpO2 95% on air with clear breath sounds but an ejection systolic murmur (ESM) (no history of angina, syncope or heart failure). There is no record of an echocardiography performed previously. The only abnormal blood results are an Hb of 103 g/dl.
She is listed for left hemiarthroplasty on your trauma list, what is your management plan?
a) Sedation with midazolam, spinal anaesthesia in lateral position with right side down, isobaric bupivacaine 0.5%, 2.3 ml with fentanyl 15 mcg
b) Sedation with midazolam, spinal anaesthesia in lateral position with left side down, hyperbaric bupivacaine 0.5%, 1.7 ml with fentanyl 15 mcg
c) Delay surgery until urgent echocardiography to determine the severity of possible aortic stenosis followed by cardiology review for preoptimization
d) Delay surgery until urgent echocardiography to determine the severity of possible aortic stenosis followed by general anaesthesia with intraoperative arterial pressure monitoring
e) Avoid delaying surgery, general anaesthesia with intraoperative invasive arterial pressure monitoring
Answer: b)
Hip fractures are more common in the frail elderly female population, with a 30-day mortality of 8.2%. The 2011 Association of Anaesthetists of Great Britain and Ireland (AAGBI) guidelines for management of proximal femoral fractures stressed the importance of a multidisciplinary team approach. The guidelines suggest consideration of spinal/epidural anaesthesia for all patients ideally with hyperbaric bupivacaine (a dose of <10 mg is associated with less hypotension) in the lateral position (bad side down) and fentanyl as the intrathecal opioid of choice. (Intrathecal diamorphine or morphine risks causing respiratory depression or confusion post-operatively.) If sedation is required for patient positioning, ideally midazolam or propofol should be used along with supplemental oxygen. Both ketamine and hypoxia may add to post-operative confusion. Hypotension should be avoided and nerve blocks should be considered for all patients in the perioperative period.
Although this patient has an ESM she does not have any symptoms suggestive of severe aortic stenosis. Investigations such as echocardiography should not delay the surgery as a delay of more than 48 hours has been shown to increase complications and post-operative mortality. Also, post-operative early mortality in patients with or without arterial stenosis is similar.
A lesser incidence of post-operative confusion, deep vein thrombosis, early post-operative mortality, pneumonia and hypoxia with regional anaesthesia was noted in a meta-analysis in 2010.
In 2014 the results of the Anaesthetic Sprint Audit of Practice Standards (ASAP) were published. The main recommendations were that spinal anaesthesia (SA) is associated with decreased occurrence of hypotension as compared with general anaesthesia (GA) and hence should be considered for all patients. Use of perioperative nerve blocks was limited in the audit and again should be offered to all patients. If the patient would benefit from GA over SA, then inhalational agents should be considered as these have been shown to offer greater cardiostability than intravenous agents in the ASAP audit. Concomitant GA and SA should be avoided as it showed the highest occurrence of hypotension when compared with other anaesthetic techniques.
Bone cement implantation syndrome (BCIS) causing hypoxia and hypotension occurred and patients undergoing cemented hemiarthroplasty should be assessed for BCIS routinely.
Further reading
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