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    原作者: J.V. Nable, Michael 文章來源: 《中華急診醫學雜志》編輯部 發布日期:2013-03-20

    Title: Trauma Fluid Resuscitation
    Authors 作者: J.V. Nable, Michael Bond, & John Greenwood

    I. Pre-hospital 院前
    a. One study found urban trauma patients only receive 17 min and 380mL of IVF before arriving at the hospital
    b. One study of patients with penetrating trauma found no statistical difference in
    mortality between those who received <100mL IVF vs >100mL IVF
    c. Large recent study of 776,000 patients showed a death OR of 1.1 in patients who
    received IVF pre-hospital
    d. More important is to get patients to the hospital quickly than to take the time to place IV in field

    II. ED management 急診科治療
    a. Permissive hypotension leads to better outcomes!
    b. Giving lots of IVF leads to increased BP and increased blood loss, which includes loss of clotting factors. This contributes to the trauma “triad of death:” coagulopathy, hypothermia, and acidosis.
    靜脈輸液過多可在升高血壓的同時增加失血量,包括凝血因子的丟失, 進而導致外傷“死亡三要素“的產生:凝血功能紊亂,低溫,和酸中毒。
    c. In patients with significant blood loss and persistent hypotension/AMS despite 1L
    IVF, move quickly to massive transfusion protocol (1:1:1 PRBC, FFP, platelets), leads to better outcomes
    d. ABC score (1 point for each, higher the points the higher the likelihood of benefit from massive transfusion protocol): Penetrating injury, Tachycardia (HR >120), Hypotension (SBP <90), Positive FAST
    f. CAVEAT: No permissive hypotension in patients with TBI!!!!!

    III. CCM in ED 危重病醫學在急診科的應用
    a. Lactate – if going the wrong direction, give more blood, not pressors or crystalloid
    b. Check ionized calcium when giving bloods
    c. Keep patient warm, Continuous rectal temp monitor, In-line IV warmers, Humidified air for vent
    d. Sedate and control pain (think fentanyl)
    e. Complications: Early ARDS or transfusion related acute lung injury and ACS

    References 參考文獻:
    Dalton AM. Prehospital intravenous fluid replacement in trauma: an outmoded concept? Journal of the Royal Society of Medicine 1995;88(4):213-16.
    Yaghoubian A, Lewis RJ, Putnam B, De Virgilio C. Reanalysis of prehospital intravenous fluid administration in patients with penetrating truncal injury and field hypotension. American Surgeon 2007;73(10)-1027-30.
    Haut ER, Kalish BT, Cotton BA et al. Prehospital intravenous fluid administration is associated with higher mortality in trauma patients: a National Trauma Data Bank analysis. Annals of Surgery 2011;253(2):371-7.
    Bickell WH, Wall MJ Jr., Pepe PE et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. New England Journal of Medicine 1994;331(17):1105-9.