Page 98 - Journal of Special Operations Medicine - Fall 2016

Fluid Resuscitation Urine Output 8,9
Goal: UOP of 100–200mL/h. The fluid rate should be
adjusted to maintain this level of UOP.
The principles of hypotensive resuscitation accord-
ing to TCCC DO NOT apply in the setting of extremity • Best: place Foley catheter.
• Minimum: capture urine in premade or improvised
crush injury requiring extrication. However:
graduated cylinder (e.g., Nalgene bottle [Thermo
®
Fisher Scientific, nalgene.com]).
In the setting of a crush injury associated with
noncompressible hemorrhage, aggressive fluid resusci- • Maintain goal UOP until myoglobin can be moni-
tored and normalized.
tation may result in increased hemorrhage. Balancing o If UOP is below goal at IV fluid rate of 1L/h for
the risk of uncontrolled hemorrhage against the risk of >2 hours, kidneys may be damaged and unable to
cardiotoxic levels of potassium should ideally be guided respond to fluid resuscitation. Consider:
by expert medical advice (in-person or telemedicine).
Teleconsultation, if available
Fluids 1–5 • Decreasing the fluid rate to reduce risks of volume
Goal: Correct hypovolemia to prevent myoglobin in- overload (e.g., pulmonary edema)
jury to the kidneys and dilute toxic concentrations of • Hemorrhage or third spacing may cause hypovole-
potassium to reduce risk of kidney damage and lethal mia. Consider:
arrhythmias. o Increasing the fluid rate
• Best: IV crystalloids
o Start intravenous (IV) or intraosseous (IO) admin- Urine Myoglobin 10–13
istration IMMEDIATELY (before extrication). Rate Goal: Monitor for worsening condition
and volume: initial bolus, 2L; initial rate: 1L/h, ad- • Best: laboratory monitoring of urine myoglobin
just to urine output (UOP) goal of >100–200mL/h • Better: urine dipstick monitoring of erythrocyte/he-
(see below) moglobin (Ery/Hb) 10
• Better: oral intake of electrolyte solution • Urine dipstick Ery/Hb will be positive in patients with
o Sufficient volume replacement may require “coached” myoglobinuria.
drinking on a schedule. 6 • Minimum: monitor urine color. Darker urine (red,
• Minimum: rectal infusion of electrolyte solution brown, or black), either consistently or worsening
o Rectal infusion of up to 500mL/h can be supple- over time, is associated with increasing myoglobin-
mented with oral hydration. 6,7 uria and increased risk of kidney damage.

Life-threatening hyponatremia can result from Hyperkalemia and Cardiac Arrhythmias
large-volume administration of plain water. If using oral Release of potassium from tissue damage and kidney
or rectal fluids because of unavailability of IV fluids or damage can result in hyperkalemia (5.5mEq/L), re-
access, they must be in the form of a premixed or impro- sulting in life-threating cardiac arrhythmias or heart
vised electrolyte solution to reduce this risk. 6 failure 14–17

Examples of mixed or improvised electrolyte solutions Goal: Monitor for life-threatening hyperkalemia
include the following: • Best: laboratory monitoring of potassium levels, 12-
lead electrocardiogram (ECG), cardiac monitor (e.g.,
ZOLL [ZOLL Medical Corp, www.zoll.com]; Tempus
®
• World Health Organization (WHO) oral rehydration Pro [Remote Diagnostic Technologies, http://www
™
salts (ORS): preferred
.rdtltd.com])
• Pedialyte (Abbott Laboratories, https://pedialyte.com) • Better: laboratory monitoring of potassium levels,
®
• Per 1L water: 8 tsp sugar, 0.5 tsp salt, 0.5 tsp baking soda cardiac monitor (e.g. ZOLL , Tempus Pro )
™
®
®
• Per quart Gatorade (Stokely-Van Camp Inc, www • Minimum: close monitoring of vital signs and circula-
.gatorade.com): 0.25 tsp salt, 0.25 tsp baking soda
tory examination
• Frequency: every 15 minutes for initial 1–2 hours
Monitoring • Decrease frequency to every 30 minutes, then hourly
Goal: maintain high UOP, detect cardiotoxicity, ade- if stable or if urine is clearing
quate oxygenation and ventilation, avoid hypotension, • Monitor for premature ventricular contractions (PVCs;
trend response to resuscitation. Document blood pres- skipped beats), bradycardia, decreased peripheral pulse
sure (BP), heart rate (HR), fluid input, urine output strength, hypotension
(UOP), mental status, pain, pulse oximetry, and tem- • Specific ECG signs: sinus bradycardia (primary sign);
perature on a flowsheet. peaked T waves, lengthening PR interval (early signs),

80 Journal of Special Operations Medicine Volume 15, Edition 3/Fall 2016