A 7-year-old child presents to the ED with 30% TBSA burns. His body weight is 22 kg. Using the Parkland formula, which ONE of the following is the initial intravenous fluid rate that needs to be added to the maintenance fluids?
Answer: C: The Parkland formula is the most commonly used resuscitation fluid prediction formula in both adults and children with moderate-severe burns. It calculates the 24-hour fluid requirement, of which half should be infused in the first 8 hours (counted from the time of the burn injury) and the other half over the following 16 hours. This 24-hour fluid requirement is:
4 ml/kg body weight x total burn surface area (TBSA)
In children, maintenance fluid requirement should also be added.
In this child, the initial IV fluid requirement is (without maintenance fluids) 165 mL/h for the first 8 hours.
Organ perfusion should be monitored and fluid requirement should be adjusted accordingly.
Reference:
Regarding fluid resuscitation in haemorrhagic hypovolaemia due to trauma, which ONE of the following statements is TRUE?
Answer: D: The SAFE Study compared the use of albumin and normal saline in resuscitation of ICU patients and showed that there is no significant difference in mortality, ICU length of stay (LOS) or duration of mechanical ventilation.
Class I haemorrhagic shock (<15% or 750 mL of blood loss) where there is no or minimal tachycardia and no change in BP, is typically not associated with orthostatic changes to the BP, provided the patient was not initially dehydrated.
Class II haemorrhagic shock (15–30% or 750–1500 mL blood loss) is associated with tachycardia, narrowed pulse pressure, mild–moderate hypotension with peripheral vasoconstriction and potential changes in mentation. The basis of hypotensive resuscitation in trauma is to prevent increased arterial blood loss from uncontrolled bleeding sites due to overly aggressive fluid resuscitation until surgical control of bleeding is achieved. In hypotensive resuscitation, the systolic BP is maintained at 80 mm Hg unless there is evidence of end-organ hypoperfusion. End-organ damage may be seen as myocardial ischaemia, renal failure or cerebral ischaemia and in these situations adequate end-organ perfusion should be maintained with fluid resuscitation and emergent surgical control of bleeding. Hypotensive resuscitation is contraindicated in a head-injured patient where maintenance of cerebral perfusion pressure is dependent on the blood pressure.
The standard haemodynamic measurements do not measure the physiologic derangements of a patient in haemorrhagic shock. The initial lactate level and base deficit seem to be useful in quantifying the degree of ongoing fluid resuscitation requirements and one of the targets of resuscitation is to normalize this during the first 24 hours. Additionally, the time taken to normalize the same is considered as circulatory predictors of survival of a trauma patient.
References:
Which ONE of the following is NOT a component of damage control resuscitation (DCR)?
Answer: B: The DCR is indicated in patients with severe class IV haemorrhage who require massive transfusion and immediate damage control surgery (DCS). The clinical scenario could be traumatic or non-traumatic in nature. The aim of DCR is to avoid the ‘lethal triad’ of hypothermia, coagulopathy and metabolic acidosis, which is made worse with the injudicious use of crystalloid.
The components of DCR include:
Once the coagulopathy, hypothermia and metabolic acidosis are subsequently corrected in a critical care facility, the definitive surgical procedure can be carried out as necessary.
Considering massive transfusion, which ONE of the following statements is CORRECT?
Answer: C: Massive transfusion is defined, in adults, as replacing >50% of the patient’s blood volume in 4 hours or 100% over 24 hours. The adult blood volume is approximately 70 mL/kg. In children, it is defined as transfusion of >40% of blood volume. The blood volume in a child over 1 month of age is approximately 80 mL/kg.
The aetiology of high mortality associated with massive transfusion is usually multifactorial. The factors that could contribute to high mortality include hypotension, acidosis, coagulopathy, shock and the underlying pathologies in the patient. The triad associated with highest mortality are acidosis, hypothermia and coagulopathy.
A massive transfusion may be required in the clinical situation of severe trauma, surgery, ruptured aortic aneurysm, gastrointestinal haemorrhage and during obstetric complications. It is recommended that individual institutions should develop a massive transfusion protocol to be used in patients who potentially require massive transfusions. It has been shown that there is a survival advantage when a massive transfusion is associated with a decreased ratio of RBCs to FFP, platelets or cryoprecipitate/ fibrinogen concentrate. In trauma patients, a ratio of ≤2:1:1 seems to be associated with improved survival. In non-trauma patients currently there is insufficient evidence to support or refute the use of a defined ration of blood components.
During massive transfusion, the monitoring of the following is recommended every 30–60 minutes:
The following should be aimed during massive transfusion:
Regarding trauma systems for timely management of patients with traumatic injuries, which ONE of the following is TRUE?
Answer: A: The essential characteristics of level 1 trauma centres are:
Death from trauma shows a trimodal distribution with the first peak in the prehospital stage where deaths are from devastating head and vascular injuries, then the first hour in the ED where deaths occur from major head injury, chest and abdominal injuries. The third peak occurs in the ICU where the cause of death is from the SIRS response, severe sepsis and multiorgan failure.
Trauma calls are initiated on the basis of anatomical, physiological or dangerous mechanism criteria – any one or a combination of these.
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