When Minutes Matter: Rapid Infusion in Emergency Care

Abstract

Purpose of Review This review provides historical context and an update on recent advancements in volume resuscitation for circulatory shock. Emergency department providers who manage critically ill patients with undifferentiated shock will benefit from the insights of early pioneers and an overview of newer techniques which can be used to optimize resuscitation in the first minutes of care. Recent Findings Rapid infusion of fluids and blood products can be a life-saving intervention in the management of circulatory and hemorrhagic shock. Recent controversy over the role of fluid resuscitation in sepsis and trauma management has obscured the importance of early and rapid infusion of sufficient volume to restore circulation and improve organ perfusion. Evidence from high-quality studies demonstrates that rapid and early resuscitation improves patient outcomes. Summary Current practice standards, guidelines, and available literature support the rapid reversal of shock as a key priority in the treatment of hypotension from traumatic and non-traumatic conditions. An improved understanding of the physiologic rationale of rapid infusion and the timing, volume, and methods of fluid delivery will help clinicians improve care for critically ill patients presenting with shock. Clinical Case A 23-year-old male presents to the emergency department (ED) after striking a tree while riding an all-terrain vehicle. On arrival at the scene, first responders found an unconscious patient with an open skull fracture and a Glasgow coma scale score of 3. Bag-valve-mask (BVM) ventilation was initiated, and a semi-rigid cervical collar was placed prior to transport to your ED for stabilization while awaiting air transport to the nearest trauma center. You are the attending emergency medicine physician at a community ED staffed by two attending physicians, two physicians assistants, and six nurses covering 22 beds. On ED arrival, the patient has no spontaneous respiratory effort, and vital signs are as follows: pulse of 140 bpm, blood pressure of 65/30 mmHg, and oxygen saturation 85% while receiving BVM ventilation with 100% oxygen. He is bleeding profusely through a gauze dressing applied to the exposed dura. The prehospital team was unable to establish intravenous access. What are the management priorities for this patient in shock, and how should his hypotension best be addressed?

Prehospital Plasma Is Noninferior to Whole Blood for Restoration of Cerebral Oxygenation in a Rhesus Macaque Model of Traumatic Shock and Hemorrhage

“…While physiologically similar to an adult human, animals used in this study were treated with considerations for pediatric transfusion based on their low weight range to avoid unnecessary mortality from inadequate resuscitation. The JTS Damage Control Resuscitation Guideline indicates children less than 30 kg should be given blood products in modified units of 10 to 15 mL/kg, while The American College of Critical Care Medicine and Pediatric Advanced Life Support Manual both suggest 20 mL/kg in as few as 5 min (6,31). Therefore, the prehospital resuscitation used here would be indicative of receiving 1.33 to 2 units of blood product over 5 min.…”

Strategies to Obtain and Deliver Blood Products Into Critically Injured Children

“…Although effective, these devices are expensive and require frequent use for staff to maintain proficiency. 8,32,33,[35][36][37][38] In our study, we observed that all trauma programs use a rapid infuser device in their ED to transfuse critically injured children, and the Belmont rapid infuser was the most common model used.…”

“…Rapid infuser devices can address these limitations while also providing a higher rate of infusion and the ability to warm refrigerated blood products to normal body temperature. Although effective, these devices are expensive and require frequent use for staff to maintain proficiency 8,32,33,35–38 . In our study, we observed that all trauma programs use a rapid infuser device in their ED to transfuse critically injured children, and the Belmont rapid infuser was the most common model used.…”

“…[12][13][14]30,31 Several inexpensive strategies can increase the rate of infusion to 4 times faster than gravity alone, including the push-pull technique using manual syringe infusion, pressure-bag infusion, and manual compression of blood product bags. [30][31][32][33][34][35][36][37][38] In clinical practice, these strategies are limited by the size and location of the vascular catheter, hand fatigue that can slow the rate of infusion over time, challenges in accurately tracking fluid volume, and difficulty in monitoring for unintended air in the tubing. [34][35][36][37] Rapid infuser devices can address these limitations while also providing a higher rate of infusion and the ability to warm refrigerated blood products to normal body temperature.…”

“…The use of gravity-dependent fluid administration is inadequate when volume loss exceeds the rate of hemorrhage 12–14,30,31 . Several inexpensive strategies can increase the rate of infusion to 4 times faster than gravity alone, including the push-pull technique using manual syringe infusion, pressure-bag infusion, and manual compression of blood product bags 30–38 . In clinical practice, these strategies are limited by the size and location of the vascular catheter, hand fatigue that can slow the rate of infusion over time, challenges in accurately tracking fluid volume, and difficulty in monitoring for unintended air in the tubing 34–37 .…”