GSW victim

NCgirl · Oct 4, 2005

Here's a clinical experience I had that was a great learning case.
I worked a weekend shift this past Sunday and was (un?)fortunate enough to get my first trauma experience. A GSW to the abdomen, no perforation to the liver or spleen, young (24) and otherwise healthy patient. They came in with a BE of -18, first ABG 7.14/33/210/12 ... here's my question:
How would you treat the fluid status and what would be your choice for volume replacement?

NS (and bicarb.) Check HGB, if

mwbeah · Oct 4, 2005

Here's a clinical experience I had that was a great learning case.
I worked a weekend shift this past Sunday and was (un?)fortunate enough to get my first trauma experience. A GSW to the abdomen, no perforation to the liver or spleen, young (24) and otherwise healthy patient. They came in with a BE of -18, first ABG 7.14/33/210/12 ... here's my question:
How would you treat the fluid status and what would be your choice for volume replacement?

Initially?

Probably whatever I could find...................................

Seriously, after getting a couple of large bore IVs you could use RBCs, LR, Hespan, Albumin, etc. (young and otherwise healthy, really no issues)

The most impt thing is what you have identified, volume resuscitation and monitoring gases, H/H, etc. If the pt's belly is taunt, make sure that you got plenty of fluid infusing cause when they open the belly :uhoh3: uhoh.

Trauma anesthesia (intended for humor purposes):

"Fill em up with fluid and make em earn their anesthetic" :)

versatile_kat · Oct 5, 2005

:) Here's what we did ... I gave about 3 liters of crystalloid within the first 30minutes of the case, got another ABG and the BE had only come up to -14. The CRNA I was with wanted to start slowing the fluid intake down a bit, so as to avoid postop pulmonary difficulties. We calculated about a 1 liter intake/hour for fluid. By the time she went to lunch, I had gotten in 2 more liters, drawn a couple more labs, and the BE was sitting at -12.

Now comes another CRNA with a bit more experience under the belt. He says to open up my volume and get in a total of 8 liters, draw another lab and see where we sit. After the 8th liter, my BE had come up to -8 (from -12). I shared the postop pulm concerns from the previous CRNA, and he laughed. He made a good point ... fix the trauma victim first, worry about the ICU patient next. He agreed that if it were an 80 yo CHF patient, the fluid admin would be different ... but for a healthy, 24 yo it's a whole new ballgame. And I agreed.

BTW, Mike ... I hear ya about the pinball machine dance with stressing times :) :)

mwbeah · Oct 5, 2005

:) Here's what we did ... I gave about 3 liters of crystalloid within the first 30minutes of the case, got another ABG and the BE had only come up to -14. The CRNA I was with wanted to start slowing the fluid intake down a bit, so as to avoid postop pulmonary difficulties. We calculated about a 1 liter intake/hour for fluid. By the time she went to lunch, I had gotten in 2 more liters, drawn a couple more labs, and the BE was sitting at -12.
Now comes another CRNA with a bit more experience under the belt. He says to open up my volume and get in a total of 8 liters, draw another lab and see where we sit. After the 8th liter, my BE had come up to -8 (from -12). I shared the postop pulm concerns from the previous CRNA, and he laughed. He made a good point ... fix the trauma victim first, worry about the ICU patient next. He agreed that if it were an 80 yo CHF patient, the fluid admin would be different ... but for a healthy, 24 yo it's a whole new ballgame. And I agreed.
BTW, Mike ... I hear ya about the pinball machine dance with stressing times :) :)

Always remember that! From experience, the postop concerns resolve if the patient is stable coming off the table. Take your time now and look at recoveries of patients from different providers and make your own judgments. My experience is if they are appropriately euvolemic, they do much better postop (much smoother recovery). I could go on why, but your learning that now.

Mike