Page 24 - Journal of Special Operations Medicine - Fall 2014

extremity or junctional injury in which bleeding has penetrating torso injuries and hypotension found that
now been controlled with an extremity or junctional those who received standard fluid resuscitation (defined
tourniquet), the hemorrhage has been effectively con- in that study as greater than 150mL of crystalloid, with a
trolled and restoration of a normal or near-normal BP mean volume infused of 2757mL) had a higher intraoper-
would be less likely to exacerbate any ongoing hemor- ative mortality (32%) than those whose fluid resuscitation
rhage. That said, casualties who have tourniquets ap- was restricted to 150mL or less (mean 129mL). The in-
plied should be continuously reassessed during and after traoperative mortality was 9% in the restricted fluid re-
fluid resuscitation to see if the fluid administered has suscitation group (p < .001). In another study on the
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resulted in recurrent bleeding from the injured extremity effect of infused crystalloid volume on mortality, volumes
or junctional area. of 1.5L or more in the emergency department were asso-
ciated with increased mortality. The patients in this study
In uncontrolled hemorrhage (e.g., casualties with pene- were not categorized by mechanism of injury or by con-
trating injury to the chest, abdomen, or pelvis), bleeding trolled versus uncontrolled hemorrhage. 25
occurs at an internal site not visible to combat medical
personnel and not amenable to prehospital hemorrhage Hampton and colleagues prospectively studied 1200
control interventions. The entry site may be inconspicu- trauma patients (65% blunt trauma; 35% penetrating)
ous and obscured by the casualty’s uniform. The combi- as part of the PRospective Observational Multicenter
nation of decreased blood flow to the bleeding site and Massive Transfusion (PROMMTT) study; 84% of pa-
the body’s clotting response may result in an initial ces- tients received prehospital IV fluids, while 16% did not.
sation of blood loss, but this cessation may be tempo- The patients in this study were not grouped by con-
rary if BP is subsequently raised and resuscitation fluids trolled versus uncontrolled hemorrhage. Injury Severity
that do not contain platelets or clotting factors are used. Scores (ISSs) were similar. The median volume of fluid
Both crystalloids and colloids dilute the concentration infused was 700mL. The authors found that prehospi-
of clotting factors in the intravascular space. The com- tal IV fluid administration was not associated with an
bined increase in BP and dilutional coagulopathy may increase in SBP but was associated with increased sur-
overwhelm the body’s attempts to achieve hemostasis at vival (hazard ratio 0.84, 95% confidence interval 0.72
the site of vascular injury. to 0.98; p = .03). 26

Sondeen and colleagues studied the BP at which animals In an analysis of a prospectively collected multicenter
with a standardized intra-abdominal injury (aortotomy) cohort of severely injured blunt trauma patients who
resuscitated with LR began to rebleed. The average BP were in hemorrhagic shock, the amount of crystalloid
at which rebleeding occurred was a mean arterial pres- given was directly associated with the incidence of ab-
sure (MAP) of 64 ± 2mmHg (SBP 94 ± 3mmHg). The dominal compartment syndrome (ACS), extremity com-
21
authors recommended that resuscitation of patients partment syndrome, adult respiratory distress syndrome
with uncontrolled hemorrhage be accomplished to an (ARDS), multiple organ failure, and infections. There
end point that would result in a BP below this level. was no observed effect on in-hospital mortality. In a
27
retrospective study of 799 patients at a Level 1 trauma
For uncontrolled (noncompressible) hemorrhage, there center, Joseph and colleagues found that the volume of
is Level B evidence that early, aggressive crystalloid re- crystalloid resuscitation was the only risk factor associ-
suscitation prior to surgical control of bleeding results ated with the development of ACS. 28
in decreased survival compared with fluid resuscitation
that is delayed until after surgical hemostasis. This was A retrospective study based on data from the Trauma
6
a prospective, randomized, controlled trial in which Registry of the German Society for Trauma Surgery
598 hypotensive patients with penetrating torso trauma compared 1351 pairs of patients with an ISS greater
were resuscitated either aggressively with Ringer’s ac- than 16 who were given relatively less (0 to 1500mL)
etate (mean 2478mL) or with only a minimal fluid vol- or relatively more (2000mL or more) prehospital crys-
ume (mean 375mL) prior to surgery. Survival was 70% talloids or colloids. This study found that those who
6
29
in the 289 patients who received the restricted volume received the larger-volume prehospital fluid resuscita-
presurgical fluid resuscitation and 62% in the 309 pa- tion received significantly more units of PRBCs (9.2
tients who received the aggressive, larger-volume early versus 6.9 units) and had significantly increased trauma-
fluid resuscitation (p = .04). These findings are consis- associated coagulopathy (72% versus 61.4%) and in-
tent with the observations made by Beecher in World creased rates of sepsis (18.6% versus 13.8%) and organ
War II and Cannon and colleagues in World War I. 23 failure (39.2% versus 36.0%). In another study from
22
Tulane examining the effect of plasma-to-RBC ratio
More recent clinical studies also support this find- in massive transfusion patients, increasing volume of
ing. 24,25 Duke’s retrospective study of 307 patients with crystalloid administration during the resuscitation was

16 Journal of Special Operations Medicine Volume 14, Edition 3/Fall 2014