If there is active bleeding visible apply local pressure to the area and elevate if able.

Consider the need for activation of major haemorrhage protocol.

Attach the patient to a cardiac monitor.

Insert one or more peripheral IV cannula. Use large bore (18G Green or 16G Gray) cannula which are suitable for drugs, IV fluid and blood transfusions if required. Take blood at the time of inserting the cannula.

If IV access is very challenging or impossible, intra- osseous (IO) access may be useful to prevent delayed management in emergency situations. Special training is required to insert IO needles. It allows fluid and drugs to be inserted into the medullary space which has a rich blood supply.

Central IV access may be an option; however, it is generally more time consuming and requires specialist training. This should only be attempted in an emergency if the operator is slick and quick.

Routinely to include renal and liver function, CRP, full blood count and coagulation.

A blood gas is useful in patients who are deteriorating to measure pH and lactate.

If concerns about blood loss – ensure a cross match is sent.

If concerns about sepsis – take blood cultures.

If concerns about acute coronary syndrome – cardiac enzymes such as troponin.

If concerned about congestive heart failure consider sending B-type natriuretic peptide (BNP).

The purpose of a fluid challenge is to see if giving a fluid bolus improves the patient’s haemodynamic status. Common indications for a fluid bolus are hypotension and oliguria.

• Give crystalloid - Hartmanns or 0.9% sodium chloride.

• 500mls over 20- 30 mins.

• Monitoring throughout for signs of fluid responsiveness.

They may not be responsive to fluid as hypovolemia is not the only cause of cardiac compromise. Therefore assessment for fluid responsiveness is essential. Consider the following:

1. Blood pressure - an improvement in mean arterial pressure (MAP)

2. Improvement in urine output > 0.5ml/kg/hr

3. Improving organ perfusion

• Lactate falling.

• Improved conscious level.

• Normalising heart rate (in tachycardic patient).

• Capillary refill time reduced.

Stop and Think: Remember that intravenous fluid is a drug, it must be prescribed. It can be harmful if used incorrectly. In patients at risk of fluid overload, give a smaller volume of fluid 100-250mls and re-assess.

Accurate input and output is essential to assess overall fluid balance. In the hypotensive patient, a urinary catheter and hourly urine output monitoring is useful to assess renal perfusion.