Circulation

A minimum of two large-caliber intravenous catheters should be established. Upper extremity peripheral lines are preferred in most cases. Central venous lines should be established if no peripheral access is possible and/or if central venous pressure monitoring is needed. When the first intravenous line is inserted, blood should be drawn for full blood count, type and cross-match, and baseline chemistry studies. A pregnancy test should be performed in females of childbearing age.

A balanced electrolyte, such as Ringer's lactate, is preferred as the initial resuscitation fluid, and 2 to 3 liters of solution may be required in the first 5 to 15 min to achieve an appropriate response in severely hypovolemic patients. If the patient is still hypotensive after rapid intravenous administration of 2 to 3 liters of crystalloids, this is often evidence of continued severe bleeding that generally needs to be controlled in the operating room.

Hypothermia can develop quickly in the emergency department if the patient is left uncovered and if the resuscitation fluids have not been warmed. A rectal or esophageal probe or thermistor built into a special bladder catheter can be used to monitor core temperature. The use of a high-flow fluid warmer to heat fluids and blood to 39 to 42 °C is recommended. The mortality and incidence of coagulopathy rise if the core temperature falls below 35 °C. If the core temperature falls below 32 °C, most patients become acidotic and coagulopathic and have greatly increased morbidity and mortality.

ECG monitoring of all patients with severe trauma is recommended. Dysrhythmias, including unexplained tachycardia, atrial fibrillation, premature ventricular contractions, and ST segment changes, may indicate cardiac contusion. A prolonged QT interval suggests hypocalcemia, and peaked T waves suggest the presence of hyperkalemia. Electromechanical dissociation may indicate cardiac tamponade, tension pneumothorax, and/or profound hypovolemia. If bradycardia, aberrant conduction, or premature beats are present, hypoxia, hypoperfusion, and/or hypothermia may be present.

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