Page 132 - Journal of Special Operations Medicine - Spring 2016

volume at which the risk for abdominal compartment • NS, Plasma-Lyte A, or oral replacement for patients
syndrome becomes significantly higher. 13,17 with head injury and no signs of elevated ICP.

Finally, oral or enteral nutrition has been studied in The following is a strategy for HTS administration:
burns up to 40% TBSA. Though not a primary solution, 250mL bolus of 3% followed by 50mL/hr basal rate for
this technique could be very useful in a resource-limited an average 80kg patient. This is approximate and, ide-
PFC environment. ally, serum sodium (Na) can be measured with point-of-
care testing (POCT) systems, such as an i-Stat.
Sepsis
The recognition of sepsis may be difficult, especially If POCT is available, the following steps are
early in the disease process. A patient should be consid- recommended:
ered septic if they have an infection (fever and/or clinical
concern such as cough productive of purulent sputum, 1. Give 250mL 3% HTS bolus IV (children: 5mL/kg)
diarrhea, urinary tract infection, skin infection, or signs over 10–15 minutes.
of systemic infection such as rigors) accompanied by an 2. Follow bolus with infusion of 3% HTS at 50mL/
elevated heart rate and/or respiratory rate. Severe sepsis hour (children: 1mL/hour).
is defined as sepsis plus organ dysfunction (e.g., altered 3. If awaiting transport; check serum Na levels every
mental status, decreased UOP, respiratory compromise). hour and respond as follows:
Septic shock is severe sepsis accompanied by decreased a. If Na <150 mEq/L, rebolus 150mL over 1 hour,
blood pressure (BP) that is not responsive to initial vol- then resume previous rate
ume resuscitation (1–2L fluid bolus). b. If Na = 150–154 mEq/L, increase 3% HTS infu-
sion by 10mL/hr
Sepsis has a large fluid requirement because of capil- c. If Na = 155–160 mEq/L, continue infusion at cur-
lary leak. Initial resuscitation (2–4L) can be attempted rent rate
with NS, but we recommend changing fluids to LR or d. If Na > 160 mEq/L, hold infusion, then recheck in
11
Plasma-Lyte A if more fluid is required. The following 1 hour
are recommended protocols: 4. Once Na is within the goal range (155–160mEq/L),
continue to follow the serum Na level every 6 hours.
• Titrate total fluids to maintain systolic BP >90mmHg 5. After cessation of 3% HTS infusion, continue to
(ideal MAP goal: >60–65mmHg) and adequate UOP monitor serum Na for 48 hours to watch for re-
(0.5mL/kg/hr). bound hyponatremia.
• Initiate early broad-spectrum antibiotic coverage (and
source control, if applicable) early.
• A good starting point is an initial 2L bolus, then Logistics (The Bottom Line on What to Pack)
500mL boluses until systolic BP is >90mmHg (MAP The following are the basic recommendations for
>60–65mmHg). Frequent rebolusing may be required deployment:
in addition to maintenance fluid if the patient is un-
able to take oral fluids or nutrition. • 3–4 FWB transfusion kits
• 3–4 500mL bags of Hextend (BioTime; http://www
Head Injury .biotimeinc.com) (if used as initial resuscitation per
18
The following are recommended : Tactical Combat Casualty Care [TCCC] guidelines)
• 1 case NS or the equivalent, with 6–8 250mL NS bags
• 3% (hypertonic) saline solution (HTS) for signs of for reconstituting IV medications, and the balance be-
significant elevated intracranial pressure (ICP): ing 1L bags
o Progressively worsening mental status (decreased • 2–3 cases LR or Plasma-Lyte A to use for large resus-
Glasgow coma score) or other signs, such as bra- citations
dycardia, widening pulse pressure, and increased • 6–8 bags (250mL or 500mL) of HTS
diameter of optic nerve sheath on ultrasound • 10–15 microdrip administration tubing sets (need for
evaluation in a known head-injured patient with maintenance and sedation drips)
adequate BP and UOP. (Remember, lowered BP
can lead to decreased mental status without head References
injury).
o If giving HTS, a maintenance fluid is likely not 1. Ball J, Keenan S. Prolonged Field Care Working Group Posi-
necessary, since nearly 100% of 3% saline remains tion Paper: prolonged field care capabilities. J Spec Oper Med.
2015;15:76–77.
in the intravascular space (250mL is equivalent to 2. Winters M. IV fluid in resuscitation [audio podcast]. http://
>1L of crystalloid). emedhome.com

116 Journal of Special Operations Medicine Volume 16, Edition 1/Spring 2016