Published Mar 7, 2005
When would you give blood to a trauma patient instead of NS or LR? What are the indications? For blood is it just when there's a low RBC count? I know you sometimes mix them, I think in a 1:3 ratio, correct? When would that be done?
Thanks in advance.
neneRN, BSN, RN
Would give blood if pt clinically appears to be having acute blood loss, i.e.-sustained hypotension, tachycardia, obvious injuries indicative of blood loss (pelvis, femur fractures, distended belly, uncontrollable bleeding, etc.) as well as a low OR dropping Hgb.
Then when would you use normal saline? For blood loss up to a certain limit?
You would definitely look at the H & H levels. If they're low, you would give blood. If the H & H is not too low, but the blood pressure is low, you can give normal saline or maybe even some 5% albumin to bring the pressure back up.
Okay, thanks. Next question. I was reading a couple of places that even suggest using 7% NaCl in trauma patients but only using 250-350 mL of the stuff. Why would I do that instead of using the 0.9% NaCl or LR? Doesn't that risk dehydrating the patient?
Use NS or LR if pt is clinically stable with minimal blood loss. We generally only give blood immediately in the situations I described above. Not every pt that has blood loss will need replacement. There's not a set "limit" as to who will need to get blood; for example, a young healthy trauma pt may lose a little volume and compensate whereas a little elderly lady who is anemic anyway and on blood thinners is going to need more aggressive treatment. Or you might have someone come in who doesn't have an obvious need for blood, but may be slowly leaking from somewhere and will end up needing that blood later on. It's one of those things where you have to assess each pt differently, depending on the type of injury as well as pt's general state of health prior to the trauma.
rjflyn, ASN, RN
Almost universally NS or LR has been used where I have worked. Mostly NS anymore as its the only thing you give blood with so your not having to change out lines or fluids to give blood. As when to give blood, when it is clinically or labatory result indicated. If you have given a pt more than a 2 liters of fluid and they are still bleeding you probably need to be thinking about blood products.
An interesting side note is that there is currently a phase III study of a synthetic blood replacement product. It is been trialled in several cities by there EMS systems. I'm not sure how many patients have recieved it but sounds promising. Here is the website-- http://www.northfieldlabs.com/polyheme.html
We use both Nss and LR...two lines for a trauma...both fluids get hung..one on each line...in a trauma situation..H/H doesn't matter so much, we do a bedside Crit just to get a baseline, by the time that drops the patient is either in the OR, dead, or in the ICU...we mostly go by VS and LOC...unresolved tachy with IVF and active bleeding...you are getting bld...Bld bank is present w/4 units UCM bld for all level 1 traumas...so those are the cases more likely to get bld than other traumas...ie gsw to abd or chest...if the pt is suspected to have massive internal bleeding...in which if its the chest and we end up putting in chest tubes..we autotransfuse...also we do bedside lactates....if they are elevated as the initial ones usually are we hang fluids, if they've gotten a significant amt of fluid and the lactate resolves, but they are still tachy..we start thinking bld products...
Traumapt-NSS until blood-if hypovalemia is evident. H&H or EMS report of gross blood loss at scene, or it is is pooling at my feet :stone
Because NaCl Is a hypertonic solution giving only a 250 ml bolus can actually increase blood volume by 500 ml or more. It also helps improve renal function something usually lacking in severly hypotensive patients
But wouldn't it still be a problem in dehydrated patients because wouldn't it be drawing fluid out of the cells?
You are thinking along the right lines; however...
do not confuse hypovolemia with dehydration. hypovolemia is a loss of intravascular or circulating fluids either actual loss such as bleeding or relative loss to redistribution (i.e. third spacing). dehydration is a fluid concentration disorder where there is not enough h2o relative to Na concentration.
The hypertonic fluid does indeed cause h20 to come out of the cell and technically cause a relative dehydration of the cell. remember a couple of things here
-hypovolemia does not necessarily equal dehydration
-the goal of trauma fluid resuscitation is to maintain some sort perfusion of oxygenated hemoglobin to vital organs
-2/3rds of total fluid in the body is intracellular so it is a potential source of h20 that can be utilized in the intravascular space
-do you really care about a relative dehydration in a patient requiring this type of fluid resuscitation...clinical decision time
250cc of hypertonic may get you 500cc from intracellular volume into the vasculature but how long will this fluid last before it either ends up on the floor or thirdspaced? if a patient is losing so much volume that you cannot maintain any sort of hemostasis with blood component, isotonic crytalloid, and colloid fluid... is a touch of hypertonic fluid going to be the silver bullet and saves the day? On the other hand, the patient is clearly having a bad day so why not try all of the guns in your arsenal.
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