Monitoring

The adequacy of resuscitation is assessed by continued monitoring of blood pressure, pulse pressure, pulse rate, ventilatory rate, urine output, arterial blood gases, and core temperature. These values need to be recorded every 5 to 15 min in critically injured patients.

1. The systolic blood pressure is often a poor measure of actual tissue perfusion; however, changes in pulse pressure often correlate well with changes in stroke volume. Class III hemorrhage (30-40 per cent of the blood volume loss), as reflected by a decreased systolic blood pressure and pulse pressure, generally indicates a need for blood as part of the fluid resuscitation.

2. Heart rates above 90 beats/min and rising are usually a sign of increasing hypovolemia or hypoxemia. A heart rate above 120 to 140 beats/min implies a class III or class IV hemorrhage.

3. In the absence of diuretics or osmotic substances in the urine, such as with glycosuria, the urine output serves as a guide to the general adequacy of tissue perfusion. A urine output below 0.5 ml/kg/h usually indicates hypovolemia.

4. Ventilatory rate and arterial blood gases should be used to monitor the patient's ventilation and oxygenation. A respiratory rate above 30 to 40 breaths/min and/or evidence of increased efforts to breathe are strong indicators of a need for endotracheal intubation and ventilatory assistance.

5. Pulse oximetry is a valuable adjunct for continuously monitoring the adequacy of tissue oxygenation; however, the SaO2 from the arterial blood gas may be 2 to 3 per cent less than the saturation shown on the pulse oximeter.

6. End-tidal carbon dioxide monitoring showing an end-tidal PCO2 of 10 mmHg (1.3 kPa) or more can confirm that an endotracheal tube is properly positioned. In addition, an end-tidal PCO2 below 25 to 30 mmHg (33-40 kPa) in a patient with a PaCO2 of 40 mmHg (5.3 kPa) or more implies that the patient is inadequately resuscitated (Domsky , et al 19.9.5).

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