02-05-2006, 05:02 AM
"Resuscitation of a hemodynamically unstable patient begins with assessing and addressing the ABCs (ie, airway, breathing, circulation) of initial management. Patients presenting with severe blood loss and hemorrhagic shock present with mental status changes and confusion. In such circumstances, patients cannot protect their airway, especially when hematemesis is present. In these cases, patients are at increased risk for aspiration, which is a potentially avoidable complication that can significantly affect morbidity and mortality. This situation must be recognized early, and patients must be electively, not emergently, intubated in a controlled setting using cricoid pressure.
Once the airway is secured, the next step in evaluation is assessing the patient's circulation. Intravenous access must be obtained. Bilateral 16-gauge (minimum) upper extremity peripheral intravenous lines are adequate for volume resuscitative efforts. Poiseuille law states that the rate of flow through a tube is proportional to the fourth power of the radius of the cannula and is inversely related to its length (Corson, 2001). Thus, short, large-bore peripheral intravenous lines are adequate for rapid fluid infusion. A rough guideline for the total amount of crystalloid fluid volume needed to correct the hypovolemia is the 3-for-1 rule. Replace each milliliter of blood loss with 3 mL of crystalloid fluid. This restores the lost plasma volume. Patients with severe coexisting medical illnesses, such as cardiovascular and pulmonary diseases, may require pulmonary artery catheter insertion to closely monitor hemodynamic cardiac performance profiles during the early resuscitative phase." - emedicine
Once the airway is secured, the next step in evaluation is assessing the patient's circulation. Intravenous access must be obtained. Bilateral 16-gauge (minimum) upper extremity peripheral intravenous lines are adequate for volume resuscitative efforts. Poiseuille law states that the rate of flow through a tube is proportional to the fourth power of the radius of the cannula and is inversely related to its length (Corson, 2001). Thus, short, large-bore peripheral intravenous lines are adequate for rapid fluid infusion. A rough guideline for the total amount of crystalloid fluid volume needed to correct the hypovolemia is the 3-for-1 rule. Replace each milliliter of blood loss with 3 mL of crystalloid fluid. This restores the lost plasma volume. Patients with severe coexisting medical illnesses, such as cardiovascular and pulmonary diseases, may require pulmonary artery catheter insertion to closely monitor hemodynamic cardiac performance profiles during the early resuscitative phase." - emedicine