MONITORING

Goal

Maintain adequate oxygenation and ventilation, avoid hypotension, trend response to resuscitation.

Vital signs

Document vital signs frequently (every 15 minutes initially, then every 30–60 minutes once stable for more than 2 hours) on a flow sheet.30

- Minimum: Document signs and symptoms that could indicate hypovolemic shock and the response to resuscitation in order of early to late appearance in shock.
  - Mental status
  - Respiratory rate
  - Heart rate
  - Peripheral pulses
  - Blood pressure
  - Also document temperature and pulse oximetry
- Better: In addition to minimum requirements, monitor capnometry (displaying end-tidal CO2 (EtCO2) value, ideally with waveform).
- Best: Portable monitor providing continuous vital signs display; capnography

Urine output

Urine output (UO) is a valuable indicator of adequate resuscitation from hemorrhagic shock.

- Minimum: If patient can void, capture urine in premade or improvised graduated cylinder.
  - Collect all spontaneously voided urine and carefully measure; more than 180mL every 6 hours is adequate for adults.
  - A Nalgene® (Thermo Fisher Scientific, http://www.nalgene.com/) water bottle is an example of an improvised graduated cylinder.
- Best: Place Foley catheter and record UO hourly.

Laboratory tests

The utility of laboratory tests in the field setting should not be overlooked for simpler and readily available measurements, like UO. When a portable laboratory device is used, it may be useful to trend the following laboratory test values along with vital signs and UO to obtain a more exact clinical picture.

- Minimum: None
- Better: Check initial point-of-care lactate concentration.
- Best: Monitor one or more of the following laboratory values every 60 minutes until the patient is stabilized, then every 6 hours:
  - Lactate
  - pH and base deficit
  - Hemoglobin/hematocrit
  - INR

Note: Neurologic examination and vital signs trends are essential to identifying a deteriorating patient with traumatic brain injury (TBI). Monitoring EtCO2 is critical for patients with severe TBI. Ensure this capability is available.