Would you push fluids or not?

[medic_texas]

Giving fluid before surgery is very common. Making him hypothermic isn't an issue pre-hospital. The patient is obviously bleeding internally, giving him fluid won't hurt him. When the patient is at the ER then blood will be given, but until then you should be doing whatever you can (and pre-hospital that is FLUID REPLACEMENT) to help.

Seriously, a Hgb of 8.2 (I had to reread the OP) and you people are yelling about giving him blood and actually considering not giving him fluid. Amazing..

"Salt water", wow.. It's more than just salt water but you should know that

Bottom line, short transport time with 200mL of fluid replaced. I believe this patient to be "dry" and in a compensatory state of shock. Giving this patient a liter or 2 of fluid pre-hospital would not turn his blood into "kool-aid" nor would it drop his Hgb to 4.

wow

[Katiebug]

Giving fluid before surgery is very common. Making him hypothermic isn't an issue pre-hospital. The patient is obviously bleeding internally, giving him fluid won't hurt him. When the patient is at the ER then blood will be given, but until then you should be doing whatever you can (and pre-hospital that is FLUID REPLACEMENT) to help.

Seriously, a Hgb of 8.2 (I had to reread the OP) and you people are yelling about giving him blood and actually considering not giving him fluid. Amazing..

"Salt water", wow.. It's more than just salt water but you should know that

Bottom line, short transport time with 200mL of fluid replaced. I believe this patient to be "dry" and in a compensatory state of shock. Giving this patient a liter or 2 of fluid pre-hospital would not turn his blood into "kool-aid" nor would it drop his Hgb to 4.

wow

Got to agree with this. Although with the information presented, it was still a judgement call. I can't say the medics on scene were wrong because they probably not aware of the real amount of blood loss. With an estimated 1.5 L frank blood on scene though, the book says to bolus 1-2 L NS or LR.

Easy to say looking at it from this standpoint and having time to think about it. I'm pretty sure I would have run a L wide open then TKOed a second. Again, I wasn't there and will not call the medics out on the carpet that were without them being able to explain.

[krumel]

Hmmm... From my point of view it seems at least reasonable what they did.

For me this is a definitive canidate for an ""small volume resuscitation", our protocols suggest an bolus of 250ml of HyperHAES (Contains 15g of HAES 200.000d, 18g of Natriumchlorid => pretty hypertonic). This we would have pushed togehter with another 250ml of normal crystalloid fluids.

BUT: Normally a RR of 90 without any signs of severe shock is nothing we normally threat due to the fact that a "preventive" shock threatment has been shown as an source of problem cause it increased the speed the severe shock developed. (Remember: When you push the fluids the patient will dilate his vasculars again, quit centralizing, etc. and will become unstable faster than before)

So IMHO the crew did very well...

[BushyFromOz]

If he's got a good pressure and isn't showing signs of inadequate perfusion then there's no benefit to the patient by overloading him with fluids. If his systolic was less than 80 mmHg it would be a different story, but even then I would likely start with a 500 mL bolus and then reassess. It's still not necessary to dump an entire liter of fluid or more just because you can.

Yeah, this would be myplan of action. Blood loss aside, his number are still ok relatively speaking. I COULD jam a whole 20ml/kg in him, but seeing his number are alright and hes not obtunded, i give a little bolus and then reassess. Im not sure i would give this guy 2 larg bore IV's though, but thast just reading from the forum, may be different if was looking at the guy.,

Im curious though, i saw earlier a couple of posts earlier about this being a chrinc slow bleed as evidenced by malena. Either way its sitting in the guys intestine and not circulating. Whats the diference between having blood mixed with shit in your bowel and having it on the dash of you truck?? why would he not already be shocked before he painted the inside of his rig??

[p3medic]

Giving fluid before surgery is very common. Making him hypothermic isn't an issue pre-hospital. The patient is obviously bleeding internally, giving him fluid won't hurt him. When the patient is at the ER then blood will be given, but until then you should be doing whatever you can (and pre-hospital that is FLUID REPLACEMENT) to help.

Seriously, a Hgb of 8.2 (I had to reread the OP) and you people are yelling about giving him blood and actually considering not giving him fluid. Amazing..

"Salt water", wow.. It's more than just salt water but you should know that

Bottom line, short transport time with 200mL of fluid replaced. I believe this patient to be "dry" and in a compensatory state of shock. Giving this patient a liter or 2 of fluid pre-hospital would not turn his blood into "kool-aid" nor would it drop his Hgb to 4.

wow

Giving fluid before surgery is very common IN THE HOSPITAL. Making him hypothermic begins in the ambulance. 2 liters of saline to a patient who is bleeding, without the ability to stop the bleed or replace the blood is a bad idea. Its been a bad idea for over a decade. In the field 99% of services don't have access to his H+H, so its not even a factor. Giving this patient 2 liters of saline will make him more hypothermic, coagulopathic and increase the likelyhood of increased bleeding with no benefit. Wow.

[medic_texas]

So, everyone who is bleeding does not get a fluid bolus? GI bleeds, stabbings, trauma, etc? Gotcha

If you're so worried about hypothermia, place a couple hot packs on the patient along with a few blankets to cover them up. Then maybe turn the heater on. You still have some ability to warm a patient.

I would still give 1L and a 2nd bag going at 100mL/hr.

[CBEMT]

Does nobody else have IV fluid warmers in the trucks?

[Arizonaffcep]

Does nobody else have IV fluid warmers in the trucks?

Heck yes! We (even in Southern AZ) keep it in use year round. It's much to easy to take a person's temp down with cold fluid, than it is to raise it.

[bryan20w]

Maybe i missed it but i don't think that anyone has brought up that Hypotension that is present although minor is stage 3 shock. This pt needs fluid and of the 1-2 liters that you give only 25% will stay intervascular after 1 hour. Also keep in mind that RBC's are produced based on hypoxia of the renal arteries so no saline does not carry O2 however adiquite pressure throught the renal arteries with Hypoxia present means production of more RBC's.

[spenac]

Just pointing out that we can live with low levels for a while if problem corrected.

"That evening Mrs. M. underwent another surgical procedure. All active bleeding was stopped but Mrs. M. 's hemoglobin had dropped to a dangerous 2.3 g/dL (normal range for females: 12.0 - 16.0 g/dL). Mrs. M was immediately placed on a regimen of Procrit and intravenous iron to enhance her body's production of blood. She required assistance with her breathing for a few days.

Five days after being rushed to The University Hospital in very serious condition she was transferred to the progressive care unit with a hemoglobin level of 5.0 g/dL, where she was able to sit up in bed, eat real food and visit with her many happy visitors. Mrs. M continued to regain her strength and was eventually discharged home with a hemoglobin of 6.6 g/dL (and climbing) twelve days after the doctors at the other local hospital had stated that nothing more could be done for her. "

http://www.theuniversityhospital.com/blood...casestudies.htm