Page 23 - Journal of Special Operations Medicine - Fall 2014

Discussion do not take any of these factors into account. Previous
ATLS recommendations for initial fluid resuscitation of
Water comprises 60% of human body weight. Two- patients in shock called for a large volume (2L) of crys-
thirds of body water (40% of body weight) is intracellu- talloid, despite the dubious benefits of this intervention.
lar and one-third of body water (20% of body weight) is The recommended initial crystalloid volume in ATLS is
extracellular. Of the extracellular water, three-quarters now 1L. Infusion of large volumes of crystalloid may
16
(15% of body weight) is interstitial and one-quarter result in pulmonary edema, displacement of forming
(5% of body weight) is intravascular. 15 clots at sites of vascular injury, abdominal compartment
syndrome, acidosis, worsening of cerebral edema, and
There are a number of indications for IV fluid resus- dilutional coagulopathy. 17,18
citation, including sepsis, dehydration, burns, and
hemorrhagic shock. This report will focus on fluid re- The applicability of even high-quality evidence to a par-
suscitation from hemorrhagic shock. There are four ob- ticular clinical question is limited by the degree to which
jectives of prehospital fluid resuscitation for casualties the characteristics of the patients to be treated match the
in hemorrhagic shock: inclusion criteria for the study cited. In order to under-
stand fully the information obtained from fluid resusci-
1. Enhance the body’s ability to form clots at sites of tation studies in trauma patients and to know how best
active bleeding with platelets, plasma, and RBCs; to apply that information, one must consider the type of
2. Minimize adverse effects (edema and dilution of clot- hemorrhage that produced the shock state (controlled
ting factors) resulting from iatrogenic resuscitation versus uncontrolled), the specific resuscitation fluids
injury; used, the severity of the shock that is being treated, the
3. Restore adequate intravascular volume and organ per- volume administered, the presence or absence of TBI,
fusion prior to definitive surgical hemorrhage control; and the types and amounts of other fluids given in addi-
4. Optimize oxygen carrying capacity insofar as feasible. tion to the fluids that are the primary focus of the study.
The need for caution in interpreting the results of re-
This report will consider both the volume of fluid to be suscitation in trauma patients without considering the
administered and the types of fluid that will be of most types of inclusion criteria noted here was highlighted
benefit in achieving these four objectives. recently by Dries. 19

The goal of restoring intravascular volume is the only ob- For example, the Ben Taub prospective, randomized trial
jective that can be met by all of the resuscitation fluid on the early use of large-volume crystalloid resuscitation
options that will be discussed. Restoration of oxygen- prior to surgical control of bleeding in hypotensive vic-
carrying capacity can be accomplished only with RBC tims of penetrating thoracoabdominal trauma is the best
units or whole blood. Platelets can only be replaced by evidence available for that subset of trauma patients.
6
transfusing platelets or whole blood. Coagulation factors If, however, the same question is asked for hypotensive
can be replaced by transfusing whole blood or either liq- victims of blunt or blast trauma, there is no assurance
uid (never frozen) or thawed plasma, or reconstituted DP. that the answer will be the same. The evidence produced
by a study is applicable only to patients who both meet
Resuscitation from hemorrhagic shock has historically the inclusion criteria and are treated in similar circum-
been based on limited evidence. There was no strong stances. A caveat of the Ben Taub study is that the mean
evidence of equivalent efficacy before transfusion prac- transport time was 15 minutes. That limits the appli-
tice moved from whole blood to blood component cability of the study’s findings for casualties in military
therapy after the latter option became practical in the operations, where evacuation times may average 2 to 4
early 1970s. There is Level B evidence that large- volume hours, as they did in Operation Desert Storm. Much
20
crystalloid resuscitation in trauma patients with un- longer evacuation times have been seen in other com-
controlled hemorrhage and shock increases mortality, bat actions, such as the Battle of Mogadishu (15 hours),
yet this remains common practice. Blunt trauma pa- early entry into Afghanistan and Iraq (4 to 6 hours), and
tients may not benefit equally from fluid resuscitation recent military operations in Africa (4 hours).
strategies that are based on evidence from studies of
penetrating trauma patients. Patients with shock from
hemorrhage that has been controlled may not be best Resuscitation Fluid Volume—
served by resuscitation strategies based on evidence ob- Uncontrolled Hemorrhage
tained in studies of noncompressible hemorrhage. The The optimal volume of resuscitation fluid is not neces-
presence of TBI in addition to hemorrhagic shock may sarily the same for those patients with controlled hem-
also require modifications to fluid therapy in order to orrhage and those with uncontrolled hemorrhage. In
optimize outcomes, yet fluid resuscitation strategies often controlled hemorrhage (e.g., casualties with isolated

Fluid Resuscitation for Hemorrhagic Shock in TCCC 15