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The management of hemorrhagic shock in trauma patients can be challenging for emergency and critical care providers. Rapid and efficient resuscitation is key to hemodynamic stabilization, but this crucial intervention is complicated by the possibility of inducing hypothermia while administering refrigerated blood products. Infusing 500 mL of cold blood can reduce a patient’s core body temperature by 0.5-1°C.¹ Hypothermia may lead to further acute complications, such as acidosis and coagulopathy.²

The use of a warming device is therefore recommended to avoid hypothermia during large-volume blood transfusions. Unfortunately, warming devices are often incompatible with conventional rapid fluid resuscitation techniques, including the push-pull method and pressure bags. Warming devices also take time to set up and require specific provider training, both of which can further delay care.

The following case demonstrates the benefit of using a handheld rapid infuser in tandem with an inline fluid warmer to rapidly administer multiple fluid boluses and units of warmed blood products to a trauma patient experiencing hypotensive shock.

Case Presentation & Challenges

 An adolescent male patient with no prior medical history was transported to the emergency room following a motor vehicle collision (MVC) where he was ejected from the vehicle. Vital signs on arrival included SBP of 90, heart rate 130 (shock index 1.4), oxygen saturation of 70%, and a GCS of 9. Within several minutes blood pressure was undetectable, though he did have palpable femoral pulses. He was also noted to have absent breath sounds on the left. After administration of two units of whole blood and placement of a left thoracostomy he was intubated. A FAST exam revealed a large amount of free fluid in the abdomen and the patient was taken to the operating room for exploratory laparotomy. He was found to have a grade V liver laceration, which required a partial liver resection and 12 units of blood products in the OR. His abdomen was left open with a wound vac in place for re-exploration in the subsequent days. 

The patient arrived in the PICU after surgery intubated, sedated, and hemodynamically stable. Shortly after arrival, his systolic blood pressure (SBP) rapidly fell to the 70’s and then to 40 mmHg. 

Management 

Anticipating imminent cardiac arrest due to severe hypotension, the team immediately identified the need for rapid resuscitation. After calling for stat blood products from the blood bank, nurses administered three 500 mL boluses (total 1500 mL) of warmed normal saline over five minutes using the LifeFlow Plus rapid infuser and a QinFlow warmer. Between each bolus, vital signs were reassessed, and the patient’s SBP rose briefly before falling again. 

The nurse then administered two units of packed red blood cells (PRBCs), both containing 300 mL, each over two minutes using the LifeFlow infuser and QinFlow warmer for continued severe hypotension. Two units of fresh-frozen plasma (FFP), each containing 250 mL, were given over two minutes per unit with LifeFlow and QinFlow warmer. A unit of cryoprecipitate (Cryo) was also initiated. All infusions were administered through an 18-gauge peripheral IV. 

As the blood was delivered, the patient’s SBP rose steadily to the 120’s and his capillary refill returned to less than three seconds. Thanks to this rapid response, vasopressors were not needed to stabilize the patient. He was taken immediately to CT scan to determine if further surgery was needed. No active bleeding was identified, and the patient remained stable for several days before returning to the OR for re-exploration and closure of his abdominal incision. His acute episode of hypotension was thought to be due to re-bleeding at the site of his liver injury, which had stopped after he received several units of blood products. He spent roughly one week in the hospital before returning home. 

Discussion 

For patients with hemorrhagic shock and severe hypotension, immediate resuscitation is essential to prevent further organ injury and cardiovascular collapse. This is particularly important when traumatic brain injury (TBI) is present since every minute of hypotension in TBI results in higher mortality.³ Whole blood is the fluid of choice for hemorrhagic shock, but since blood products are not always immediately available crystalloid may be the only initial option. Though much has been written about the potential harms of fluids for trauma, normal saline is readily available and can be used for immediate treatment of severe shock with hypotension. A large study of pediatric trauma patients showed that an initial saline dose of 20ml/kg was safe and effective for the early treatment of hemorrhagic shock.⁴ Fifty percent of patients in this study who got fluid for their initial resuscitation required no blood products. Patients who received > 20mL/kg of crystalloid before blood were more likely to spend longer in the ICU and on a ventilator, though other outcomes were similar. Since the presence of hypotension is the single biggest risk factor for death in pediatric trauma, we need to recognize shock early and treat hypotension immediately, even if that means the first fluid bolus is crystalloid.⁵ Then we should move as quickly as possible to blood products for further resuscitation if necessary. In this case blood would have been the ideal first choice for the patient’s acute hemorrhagic shock, but he was effectively stabilized with a modest dose of crystalloid while blood was being delivered to the ICU. 

It is also important to remember that hypothermia can be exacerbated by delivery of cold fluids and can lead to worsening coagulopathy. Unfortunately, fluid warmers are often not available in the early minutes of care or are difficult and time consuming to set up. Also, many warmers may not be compatible with rapid administration of fluid or blood. 

The nursing team in this case found the pairing of LifeFlow Plus and the QinFlow warmer “fast to get set up and start using.” The team noted that there were no other compatible rapid infusers in the PICU for delivering warmed blood products and that using push-pull boluses would not have been fast enough to stabilize the patient without the use of vasopressors. 

One nurse who treated the patient said, “LifeFlow greatly impacted this patient’s outcome because we could quickly grab and set it up to have fluids started within two minutes of his blood pressure dipping until we could get blood to the unit.” 

“LifeFlow allowed us to rapidly resuscitate this patient in order to get him safely to CT” she added. 

When trauma patients need blood or fluid given rapidly, lack of adequate infusion and warming methods can delay effective resuscitation. The compatibility of LifeFlow with the QinFlow Warrior warmer allows for the seamless administration of warmed fluids and blood products. Both devices are easy to set up and start operating in minutes with minimal training, equipping providers to safely and efficiently and safely provide rapid resuscitation while preventing hypothermia.