Circulatory management

• Patients are often cold and vasoconstricted on admission. This serves to camouflage concurrent hypovolaemia and compromise tissue perfusion.

• Adequate monitoring must be instituted at an early stage.

• Development of a persisting tissue oxygen debt has been shown to lead to subsequent multiple organ dysfunction which may not become clinically apparent for 3-7 days. Therefore, adequate perfusion must be restored promptly by repeated fluid challenges. Addition of a vasodilating agent, e.g. glyceryl trinitrate, may be beneficial.

• An increasing metabolic acidosis should prompt suspicion of inadequate resuscitation, covert haemorrhage or tissue necrosis. Myocardial depression or failure may also be implicated.

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