Treating patients with prolonged dehydration/heat exposure

[FormerEMSLT297]

We recently had a call of a hiker who got lost in the woods for a period of 8 days, he suffered a fall of about 25 feet of a rock face and was found stranded there with multiple injuries.

He was obviously very dehydrated, shriveled up skin, warm dry to touch, cracked lips, etc.

He had several lacerations, a FX femur, and several abrasion/ minor lacerations to the head. It is known based on his back country permit, that he was in to woods for 7-8 days without food or water. He fell into a stream and told rescuers he occasionally drank water from the stream.

V/S BP 150/80 HP 130 HR 18 PO2 97 %. Obviously we boarded collared him, high con O2, I.V.

But my question is: Rapid rehydration? KVO rehydration or something in between.

Will rapid rehydration "Shock his kidneys" too much, or maybe save him if he is on the brink of renal failure.?

If anyone has any good factual articles on the subject please post them up. Thanks

[Doczilla]

Initially, rapid hydration to the tune of 2-3 liters or so of isotonic crystalloid. You will not "shock the kidneys" by doing this. He needs aggressive fluid resuscitation. After that, fluid deficits should be corrected more slowly with IVF, usually over the course of 48 hours or so.

Calculate it as follows:

Assume 15% dehydration based on signs and symptoms, which you have described. Take 15% of his body weight in kg, that's how many liters he's dry.

Let's use round numbers for this example. Say that he weighed 220 pounds at the start of his trip, or 100 kg. Thus he is now 15kg dry, at around 190 lbs or 85 kg.

So he needs 15 L of fluids total (1L of water=1kg. Thank God for the metric system). You wouldn't want to give him that amount IV as a bolus over a few hours, because you want to allow time for the fluid to shift.

Subtract the bolus you gave initially, and let's argue that you gave 2L as an initial bolus. He therefore needs 13L more slowly.

Take 13 L, or 13,000cc, and divide by 48 hours. This works out to 270cc/hour.

You have to account for maintenance fluid as well, so don't forget that. He's 100 kg, or at least he's using fluid like a person who is 100 kg. For any person with body weight above 20kg, you take their weight in kg and add 40. This is the number of cc's per hour of IVF they should receive. This means that your patient should get 140cc/hr as maintenance.

So 140cc/hr (maint) plus 270cc/hr (rehydration) gives you at total fluid rate of 410cc/hr.

That's if he's doing IVF only. Account for anything he's taking in by mouth and subtract that from your IVF rate.

We're also not accounting for anything he'll lose through diarrhea from drinking stream water. Crypto shouldn't set in for another week or so, but giardia or E. coli may start hitting him now.

'zilla

[Arizonaffcep]

'Zilla left out one thing (which is something us in the Southwest have a minor specialty in), with all that walking/falling dehydration, the rapid fluid bolus will also help to flush the kidneys out for what is bound to be a good case of Rhabdo.