Fluid Management in Traumatic Shock: A Practical Approach for Mountain Rescue

Abstract

Sumann, Günther, Peter Paal, Peter Mair, John Ellerton, Tore Dahlberg, Gregoire Zen-Ruffinen, Ken Zafren, and Hermann Brugger. Fluid management in traumatic shock: a practical approach for mountain rescue. High Alt. Med. Biol. 10:71-75, 2009.-The management of severe injuries leading to traumatic shock in mountains and remote areas is a great challenge for emergency physicians and rescuers. Traumatic brain injury may further aggravate outcome. A mountain rescue mission may face severe limitations from the terrain and required rescue technique. The mission may be characterized by a prolonged prehospital care time, where urban traumatic shock protocols may not apply. Yet optimal treatment is of utmost importance. The aim of this study is to establish scientifically supported recommendations for fluid management that are feasible for the physician or paramedic attending such an emergency. A nonsystematic literature search was performed; the results and recommendations were discussed among the authors and accepted by the International Commission for Mountain Emergency Medicine (ICAR MEDCOM). Diagnostic and therapeutic strategies are discussed, as well as limitations on therapy in mountain rescue. An algorithm for fluid resuscitation, derived from the recommendations, is presented in Fig. 1. Focused on the key criterion of traumatic brain injury, different levels of blood pressure are presented as a goal of therapy, and the practical means for achieving these are given.

Accuracy of low-weight versus standard syringe infusion pump devices depending on altitude

“…For this reason we consider that the use of these devices may compromise the clinical status of severely injured patients who may require hemodynamic support, particularly when managing acute severe head trauma [11]. However, very light devices may also be better than nothing in particular situations such as mountain rescue operations [12, 13]. When using a low-weight device is the only available option, the recommendation to use a low-concentration solution with a high-speed flow rate in order to minimize the quantity of active drugs delivered at each bolus, is quite reasonable.…”

Notfallmedizin im alpinen Gelände – Schock-, Schmerztherapie und Atemwegssicherung

“…Auf eine Volumentherapie wird verzichtet angesichts der stabilen Kreislaufparameter, fehlender Blutungszeichen, der Gefahr einer Dilutionskoagulopathie und der kalten Umgebungstemperatur von 3°C (Begünstigung einer Hypothermie, Gefahr des Einfrierens der Infusionsleitung). Die Erstversorgung beschränkt sich auf ▶ Anlegen einer Halskrause, ▶ O 2 -Gabe über Venturimaske, ▶ Anlage einer peripheren Venenverweilkanüle [12], Beatmung bei kardiopulmonaler Reanimation [13], Einsatz von AED [14], hämorrhagischer Schock [15], Blitzunfall [16], Immobilisierung und Schienung von Frakturen [17] oder Augenverletzungen [18]. Eine Untersuchung zeigte, dass in Bergrettungsdiensten inkl.…”

“…Eine "small volume resuscitation" mit Verabreichung geringer Mengen (4 ml/kg KG) einer hypertonen Lösung (7,5 % NaCl) als Bolus erscheint insbesondere in der alpinen Notfall medizin vorteilhaft, da hierdurch auf das Mit führen großer Mengen an Volumina verzichtet werden kann. Permissive Hypotension Einhergehend mit dem Konzept der "small volume resuscitation" hat sich das Konzept der "permissiven Hypotension" entwickelt [15,52]: Bei einer präklinisch nicht stillbaren Blutung sollte ein systolischer Druck von 90 mmHg bzw. ein mittlerer arterieller Druck von ca.…”

The Quest for Evidence-Based Medicine in Mountain Areas

“…Without extensive training and practice in adverse conditions the emergency physician is not adequately prepared to make case-specific decisions and lacks the flexibility required of emergency situations. Thus, it is crucial that in-field decisions are supported by existing treatment guidelines (Brugger and Durrer, 2002;Durrer et al, 2003;Ellerton et al, 2009;Elsensohn et al, 2006;Morrison et al, 2010;Paal et al, 2007;Soar et al, 2010;Sumann et al, 2009;Tomazin et al, 2003;and Zafren et al, 2005). However, as these are based primarily on data from in-hospital settings and expert consensus with a low level of evidence, whether these guidelines are always applicable in an adverse, prehospital environment is a matter of debate.…”